Transcript Slide 1

A retrospective evaluation of errors involving oral
chemotherapy at Brighton and Sussex University
Hospitals NHS Trust
Emma Foreman, Simon Matthews and Esther Collyer
Introduction
There are an increasing number of oral chemotherapy products coming onto the market. [1] In 2008, the NPSA released a rapid response report entitled:
risks of incorrect dosing of oral anti-cancer medicines, which stressed the need for caution when prescribing, supplying and administering oral chemotherapy
as they are high risk drugs.[2] One of its recommendations was that Trusts set up individual, quality improvement systems. Therefore, there is a need to
evaluate oral chemotherapy incidents, to establish if work processes can be improved. This study aimed to quantify errors reported at BSUH Trust according
to location, stage in the medication process, actual and potential harm, oral chemotherapy drug, role of the person attributable to the error and role of the
person who found the error, and then make recommendations to reduce errors and improve patient safety.
Objectives
•
•
To quantify and characterise incident reports involving oral chemotherapy at Brighton and Sussex University Hospitals NHS Trust
Produce recommendations to prevent future incidents
Method
Errors relating to oral anticancer medicines were extracted from the Trust’s incident reporting system (Datix) between July 2008 and February 2014
The errors were then categorised according the following scheme:
• Location of the error (primary, secondary care or unknown, specialised cancer ward or non-specialised ward)
• Stage in medication process that the error occurred (prescribing, pharmacy [dispensing, verification or supply], administration and monitoring)
• Actual harm to the patient (no harm, low harm, moderate harm, severe harm, death and unable to determine)[3]
• Potential harm to the patient (no harm, low harm, moderate harm, severe harm, death and unable to determine)[3]
• The specific oral anticancer therapy involved in the incident
Results
A total of 66 incidents were reported within the study period
14
Number of occasions
Percentage of Errors (%)
60.0
50.0
6%
40.0
21%
Primary Care
30.0
Secondary
Care
50.0
20.0
24.2
24.2
73%
10.0
0.0
Prescribing
Screening/
dispensing
Adminsitration
0.0
1.5
Monitoring
Unknown
12
12
10
10
8
8
6
4
2
Unknown
13
3
2
3
2
2
1
1
3
3
2
1
1
1
0
Stage of Medication Process
Oral Chemotherapy Drug
Chart 1: Stage in the medication process that the error occurred (n=66)
Chart 2: Proportion of incidents occurring in primary care,
secondary care and unknown location (n=66)
Chart 3: Frequency with which individual drugs were involved in
errors (n=68, some errors involved more than one drug)
60.0
100.0
92.4
90.0
Haematology/Oncology
Ward
Non-specialised Ward
31%
Dispensary
56%
50.0
40.0
30.0
20.0
16.9
13.8
10.8
10.0
6.2
Percentage of Errors (%)
13%
Percentage of Errors (%)
50.8
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
1.5
0.0
1.5
0.0
0.0
1.5
Low harm
Moderate harm
Severe harm
Death
0.0
No harm
Low harm
Moderate harm
Severe harm
Death
Unable to
determine
No harm
Potential Harm
Chart 4: Location of errors in secondary care (n=66)
Chart 5: Classification of errors according to potential harm or death (n=66)
4.5
Unable to
determine
Actual Harm
Chart 6: Classification of errors according to actual harm or death (n=66)
Discussion and Recommendations
• Although most of the reported incidents were near miss incidents, the potential harm for the majority was categorised as severe or resulting in patient
death, highlighting the importance of implementing risk reduction methods.
• One fifth of errors occurred in primary care. In response to the NPSA alert in 2008, BSUH moved all oral chemotherapy patients back in-house possibly
resulting in the de-skilling of GPs and community pharmacists. A letter was sent to all GP surgeries and community pharmacists reminding them of the
NPSA guidelines and our local policy. We also plan to meet with superintendent pharmacists from the area to reinforce this message.
• 46% of errors occurred on non-specialist wards where prescribers are not familiar with oral chemotherapy drugs. Several errors involved junior doctors
who are not authorised to prescribe chemotherapy but were not aware that they were prescribing chemotherapy drugs. In some cases, oral
chemotherapy was continued inappropriately as the patient had been admitted with chemotherapy-related toxicity. An oral chemotherapy sticker (see
below) has been introduced to flag up the need for review on admission
• A common source of administration error was confusion between two different strengths of the same drug e.g. capecitabine 150mg and 500mg tablets.
As a result, we have introduced a dose banding scheme for capecitabine using only 500mg tablets. We are reviewing this for other drugs
• The main limitation to this project was the under-reporting of errors on Datix. We plan to re-audit annually to review the impact of our recommendations
References
1. Weingart SN et al. NCCN Task Force Report: Oral chemotherapy. J Natl Compr Canc Netw 2008; 6:S1-14
2. National Patient Safety Agency. Risks of incorrect dosing of oral anti-cancer medicines. NPSA/2008/RRR001. Available at: www.nrls.npsa.nhs.uk/alerts. (Accessed 5.2.2014)
3. Cousins D et al. Safety in doses: medication safety incidents in the NHS. National Patient Safety Agency 2007. Available at www.nrls.npsa.nhs.uk. (Accessed 5.2.2014)
CHEMOTHERAPY
In case of hospital admission, stop
this medicine and seek oncology or
haematology advice.