eprescribing of chemotherapy the leeds experience julie mansell, lead chemotherapy pharmacist, leeds...

ePrescribing of Chemotherapy

The Leeds Experience

Julie Mansell, Lead Chemotherapy Pharmacist, Leeds Cancer Centre

Background at Leeds Teaching Hospitals

• SJUH Opmas 1993

• Cookridge Design partners – Chemocare® 1995

• Introduced to breast cancer clinic, gradual rollout

• Cookridge site → oncology SJUH, haematology

• 60+ consultants

• 5000 patients per annum

• Oncology, haematology, BMT, trials including early phase

• Treatment given orally, day case, in-patient and ambulatory

• All chemotherapy prescribed using Chemocare®

Improved safety

2006 Journal of Quality and Safety in Healthcare

“Effect of computerisation on the quality and safety of chemotherapy prescription”

• Oncology centre in Lausanne

• Examined chemotherapy errors before and after implementation

• Classification of errors Major = drug name, dose, route of administration

• Before 141 errors in 940 prescriptions (19% major)

• After 6 errors in 978 prescriptions (0% major)

Error rate reduced from Error rate reduced from 15% to 0.6%15% to 0.6%

Marc Voeffray et al. Effect of computerisation on the quality and safety of chemotherapy prescription Qual. Saf. Health Care 2006;15;418-421

Complex prescribing – ideal target

• Narrow therapeutic index and highly toxic– potential for harm is great

• Wide range of doses e.g. Methotrexate 10mg to 12g/m2

• Dose, interval, route varies with tumour type

• Dosed on BSA, weight, fixed

• Several medicines in most regimens

• Supportive medicines to deliver safely

• Multiple day treatment with different medicines on different days• BEP – Bleomycin D2, 8,15 Etoposide D1,2 3 Cisplatin D1, 2

• Modifications for myelosuppression, renal + liver impairment frequent

• Common use of acronyms

• Classes of agents with very different uses e.g.rituximab/trastuzumab

National Drivers

• Manual for Cancer Services

Rolling quality assurance programme for cancer services Purpose - enables quality improvement both in terms of clinical and patient outcomes

2004-2007 40% ePrescribing

• Chemotherapy Services in England: Ensuring quality and safetyNational Chemotherapy Advisory Group 2009

Group established to advise DH on development + delivery of high quality chemotherapy services

“Handwritten prescriptions for parenteral chemotherapy should be replaced as soon as possible by pre-printed forms or,

preferably, by fully validated electronic prescribing systems”

• Chemotherapy measures 2011 11-3S-139 to 142 Electronic Prescribing – covers criteria for system and SOP’s

Benefits and successes (1)

• Reduces prescription errors

• Legible

• Faster for complex treatment

Benefits and Successes (2)

Quality assurance

• Consistency of prescribing

• Controls access to protocol for certain diseases only

• Central control of change

• Set maximum doses/ routes that cannot be overwritten

• Reduces variation in clinical practice

• Template sign-off by consultant, 2 pharmacists

• Calculation of patient variables e.g. GFR, BSA

Benefits and Successes (3)

Pharmacy specific

• Integrated worksheet and label preparation

• Automatic dose rounding

RAPID RESPONSE REPORT NPSA/2008/RRR04

“Doses of vinca alkaloids should be prepared for use by dilution in small volumeintravenous bags, rather than in syringes”

Additional benefits

• Audit and review of practice

• Identifies case series for research projects

• SACT dataset

• Facilitates service re-design

• Improves prescribing efficiency in clinic

• Easily accessible treatment view on admission

Specific Challenges/Limitations

Reluctance/resistance to change

• Technophobes!

• Age range/ skills of staff across MDT

• Slower for simple treatments

Find Clinical and Managerial ChampionsEmploy national drivers

Promote additional benefitsPatience and perseverance!

Training burden

• Time consuming –start up/new staff/upgrades

• Level 1 competency (prescribing scenarios)

Employ (if possible) a designated ePrescribing lead

Specific Challenges/Limitations

Loss of knowledge

• Doses of chemotherapy never learned

• Supportive medicines not appreciated

Teach and test the basics

Errors

• ePrescribing = different errors ≠ NO errors

• If template incorrect - affects multiple patients

• Depends on quality of input e.g. 0mg/ height and weight mistakes

Foster a quality cultureCheck and check again

Review common themes

Specific Challenges/Limitations

Technical challenges

• Difficult to set up templates for complex regimens

• Chronomodulation / trial dose bands

• National system – unable to make many in-house tweaks

• No administration module → paper copy for records

Be creative, but maintain safety

Future Challenges

Paper-lite

• Long established use of prescription as communication tool• Reluctance to change

Use clinical (multi-professional) championsUse local drivers – efficiency

Project group