Transcript Proactive Risk Assessment: Chemotherapy Medication Use Process

Proactive Risk Assessment:
Chemotherapy Medication Use
Process
Chemotherapy QI Committee
Confidential: Quality Improvement
Material
Committee Members
•
Patrick Stiff, MD
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•
Kevin Barton, MD
–
Marc Borge, MD
•
Mary Brush, APN, AOCN
•
Barbara Buturusis, RN
–
–
•
–
MaryAnn Collatz, RN
•
•
Linda Flemm, APN, AOCNS
•
Donna Fletcher-Gonzalez, RPh
–
•
Ellen Gaynor, MD
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Medication Safety Specialist
Pediatrics Hematology/Oncology
•
Janet Palutsis, RN
•
Ceil Petrowsky, RN
–
–
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Research Oncology Nurse
Manager CBCC
Research Nurse Manager
•
Ronald Potkul, MD
•
Marcus Quek, MD
•
Richard Ricker, RPh
•
Twana Rundle, RN, OCN
–
–
–
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Gynecology Surgery
Urology Surgery
Director of Pharamcy
Clinic Oncology Nurse CBCC
•
Michele Sumner, RN
•
Heather Wojtecki, RN
•
Rachel Wolfberg, PharmD
–
–
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Hematology/Oncology
Chairman of Medicine
Pediatrics Inpatient Manager
Agnes Natonton, RN, OCN
Inpatient Oncology Manager
David Hecht, MD
Bone Marrow Transplant
•
Inpatient Oncology Nurse
•
•
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Inpatient Oncology Pharmacist
Kathy Fujiu, RN, OCN
–
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Clinical Nurse Specialist
•
–
Ricarchito Manera, MD
Interim Manager CBCC
Teresa Fortenberry, RN, OCN
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•
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IAsst. Manager BMT
Rita Flaska, RN, CPON
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Sara Linton, PharmD
Asst. Manager CBCC
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Director CBCC
Jaime Firkus, RN
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Cindi Laporte, RN
Outpatient Oncology Pharmacist
•
–
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Executive Director Cancer Services
Mary Callaghan, RN
–
Karen Kiley, APN, AOCN
Bone Marrow Transplant
•
Pediatrics Hematology/Oncology
•
Interventional Radiology
Tina Cabala, PharmD, BCOP
Charles Hemenway, MD
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Hematology/Oncology
•
–
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Medical Director of CBCC
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Manager Homer Glen Oncology
Manager BMT
Pharmacy Manager
Miriam Volle, APN, OCN
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Bone Marrow Transplant
Confidential: Quality Improvement
Material
Project Aim
• The newly formed multidisciplinary
Chemotherapy QI Committee used the
Failure Mode and Effects Analysis (FMEA)
tool developed by the Institute for
Healthcare Improvement, to proactively
identify potential errors which could occur
in the current chemotherapy workflow.
• 42 steps in the process were examined.
Confidential: Quality Improvement
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Failure Mode and Effects Analysis
(FMEA)
• Define all steps in the process
• Identify “failure modes”
– What realities of daily practice might cause the
process to fail?
• Define impact of failure mode on overall process
– Numeric scores: Occurrence, Severity, Detection
• Make recommendations for actions to prevent
failures
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Format and Scoring
• Institute for Healthcare Improvement (IHI) format
for FMEA
• Scoring
– Occurrence – rate likelihood that failure will occur
• 1 (remote) to 10 (very high)
– Detection – rate likelihood that failure would be
detected if it occurred
• 1 (very high) to 10 (remote)
– Severity – rate severity of failure if not detected
• 1 (no effect) to 10 (terminal injury or death)
Confidential: Quality Improvement
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Format and Scoring
• Risk Priority Number is the score
– O x S x D = RPN
• RPN calculated for each failure mode and
for each step
– Each step may include multiple failure modes
• Use RPN to prioritize actions
Confidential: Quality Improvement
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Findings
• RPN for entire process: 1831
• The Steps with the highest RPNs were
identified and action plans were developed.
Step
Description
FM’s
Total RPN
39
RN Admin Chemo
5
456
7
MD Reviews Alerts
1
120
6
MD Signs Orders
1
105
40
RN Monitors For Adverse Reaction
1
100
2
MD Chooses Chemo Regimen
2
99
5
MD Verifies Orders
7
98
41
RN Regularly Checks Infusion
1
96
28
Tech Injects Med Into Bag
1
90
Confidential: Quality Improvement
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Findings with Action Plans
Step
Action
Outcome/Monitoring
39. RN administers Chemo
Implemented 2 RNs at the bedside
verifying correct rate and connection.
Dual signature required in MAR.
Implemented in March 2008.
Ongoing monitoring in Chemo
QI Committee
7. MD reviews EPIC alerts
Decreased alerts appearing in EPIC.
Completed.
6. MD Signs Orders
RN double checking for signed
orders. If unsigned orders identified
and no MD visit prior to
chemotherapy appointment, MD is
paged prior to patient arriving to sign
orders.
Discussed at Heme/Onc Division
Meeting February 2008.
Ongoing monitoring in
Chemotherapy QI
40. RN to monitor for adverse
reactions
Implemented prior to FMEAstanding orders for
anaphylactic/hypersensitivity
medications at the bedside, and RNs
remain at bedside for 1st 15 minutes
of Paclitaxel.
Reactions managed
appropriately. No errors
reported with this step.
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Findings with Action Plans
Step
Action
Outcome/Monitoring
2. MD chooses chemotherapy
regimen/evaluates previous
treatment plan.
Reevaluate Beacon protocol titles
with physician input. Discussed
physicians selecting wrong
treatment plan at Heme/Onc
Division Meeting in February 2008.
No changes to be made at
current time. Future Beacon
upgrade will allow for more
precise protocol titles.
5. MD verifies completed
treatment plan
Height and weight to be recorded
only in metric. Fewer doses
defaulting in Beacon forcing
physician to manually enter doses.
Ongoing monitoring.
41. RN performs regular checks
of infusing medications
Identified PhaSeal disconnection
issues.
Non-vesicant therapy checking
minimally every 2 hours.
Vesicant therapy via port, checking
every hour.
Closed system products
investigated. New PhaSeal
connector to be available in
2009.
Ongoing monitoring.
28. Tech draws up medication
and injects into bag
Pharmacist now verifies drug
volume prior to dilution.
Additional verification step
added in pharmacy.
Confidential: Quality Improvement
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Findings
• Continued ongoing collection of near
misses and actual errors during FMEA
process.
• The retrospective data collected indicate
steps 2, 7, 28, 39, 40 and 41 had rare
occurrences of near misses prior to the
institution of the action plans and still
remain rare.
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Findings
• The retrospective data on step 5 has a possible
2009 downward trend.
• The retrospective data on step 6 has shown
significantly improved.
• The retrospective data collected indicated
different steps having reported near misses.
• A new FMEA is started in 2009, the committee
used current occurrence data obtained
retrospectively for more accurate RPNs.
Confidential: Quality Improvement
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Chemotherapy FMEA Interventions Step #5 - 2nd Q FY09
(MD verifies completed treatment plan orders)
New
New physicians
physicians
0.45
UCL = 0.44
Emphasis on
reporting
fromfrom
all areas
Emphasis
onincreased
increased
reporting
all areas
0.40
0.35
Percent Interventions
0.30
0.25
0.20
Mean = 0.17
0.15
0.10
0.05
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Chemotherapy FMEA Interventions Step #6 - 2nd Q FY09
(MD signs orders)
New physicians
New
physicians
0.16
0.14
0.12
UCL = 0.12
Percent Interventions
0.10
Pilot
unsigned
orders
Pilot to
toinvestigate
investigate
unsigned
orders
0.08
0.06
0.04
Mean = 0.03
0.02
0.00
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Next Steps
• Started new FMEA in March 2009
• Incorporated more proactive time in our
Chemotherapy QI meeting to work on
action plans
• Continue providing feedback from the
committee to areas involved in
chemotherapy process
Confidential: Quality Improvement
Material