ChemoCare The first full year 16th March pm - 2pm Steve Evans Gail Povey With support from: Emma Hall

Purpose of session Update on where we are Pharmacy errors audits Data quality work Pharmacy interventions audit Findings Future plans

Where are we now? All tumour sites 85% of all haematology Over 500 users Wide variety disciplines Canisc interface Good time for a review of the system Bronglais Hospital, Aberystwyth Withybush Hospital, Haverfordwest West Wales General Hospital, Carmarthen Prince Philip Hospital, Llanelli Singleton Hospital, Swansea Morriston Hospital, Swansea Neath Port Talbot Hospital, Neath Princess of Wales Hospital, Bridgend Now a Service and not a Project....

Pharmacy errors audit findings Percentage of prescriptions with deviations ChemoCare introduced Sep 08 Paper system running alongside electronic All oncology regimens live in Jan/Feb 09

More Pharmacy findings cont... Percentage of deviations by type Same intervention recording system used as for paper system Worrying rise in clinically significant errors Yet pharmacy felt the system safer than paper? Antiemetic intervention Clinically Significant ChemoCare live All oncology live

Data Quality – Treatment Notes Reviewed the records of all patients in the Chemolist between 5 th and 9 th October 2009 (153 in total). Checked the following key data points: Original intent specified in notes – 75.8% Changes to treatment specified in notes – 96.7% Clinic letters pasted into notes – 77.1% Nursing advice recorded as given at the first course – 42.1% * * (excluded 8 patients who had their 1 st course on paper)

Data Quality – Chemolist Due to multiple visits the same 153 patients produced 187 attendances. Checked that at each attendance the following was recorded on the Chemolist: Clinical check completed – 93.6% * Drugs dispensed – 77.9% Drugs given – 89.9% * (compared with 53% in the NCEPOD report, future system fix to apply checks to all days of script will increase this figure further)

Allocation & Confirmation As 3 patients were on 2 protocols at the same time there were 156 separate prescriptions during the audit. The dates of allocation & confirmation were checked and those done on the same day as treatment were identified: Allocated on day – 2.6% (4) Confirmed on day – 20.5% (32)* * Figure drops to 27 (17.3%) if Carboplatin prescriptions are excluded.

Pharmacy interventions audit Prospective audit Period from February to April initially Continue indefinitely Joint review of processes Not reflective of electronic system Avoid misrepresenting the standard of prescribing Criteria for capture taken from old and new Broken down where too specific for either paper or electronic

Pharmacy interventions audit cont... Breakdown of interventions Process review - issues within the processes around chemotherapy prescribing that may impact on the processing of the prescription. Minor - defined as interventions made in response to issues that are not deemed to pose a risk of significant harm to the patient. Major - defined as interventions made in response to issues that are deemed to probably cause significant harm to the patient if not picked up by PTS staff.

Pharmacy interventions audit cont... Process issues ReasonDescriptionExample Not recording the drugs given* Following treatment on the system, there is a requirement to record the drugs as given via an additional screen Drugs from previous treatment not showing as given in prescription Deferring interventions* These relate to users of the system deferring treatment incorrectly but do not pose a risk to the patient, i.e. chemotherapy is late on system Patient arrives for treatment on the correct date but treatment has been deferred too far into the future. Patient has been reviewed and due to continue but the next courses have not yet been prescribed

Pharmacy interventions audit cont... Minor interventions ReasonDescriptionExample Insufficient or no intent present There is no clear intent in the patient record Intent form missing or not signed. Intent not clearly defined with planned protocol, number of cycles and any other treatments/ tests No note referring to dose modification* A dose modification is applied without adequate explanation Reason code of ‘ENTRY ERROR’ inappropriately used or complex cases without treatment notes to clarify

Pharmacy interventions audit cont... Minor interventions ReasonDescriptionExample Patient not reviewed Patients should be reviewed at regular intervals Reviews should be documented in the treatment notes. Presence of clinic letter Antiemetic prescribing intervention Applying the antiemetic policy incorrectly Wrong drug or dose prescribed without reason Incorrect drug note*When drugs are substituted in the system, there is a requirement to amend the administration note too Oral drugs substituted for IV but IV drug notes still appear on prescription or vice versa

Pharmacy interventions audit cont... Major interventions ReasonDescriptionExample Incorrect dose prescribed Incorrect dose on prescription Modification of drug applied to one cycle but not applied to remainder of cycles. Doses calculated with old GFR. Renal function dose adjustment required following blood results. Dose cap overridden without reason stated Wrong treatmentTreatment ordered differs from the intentIncorrect treatment selected and differs from intent. Includes circumstances where the individual drugs/doses may be correct, e.g. adjuvant vs advanced Trastuzumab, but may have an impact at a later date (wrong number of courses)

Pharmacy interventions audit cont... Major interventions ReasonDescriptionExample Supportive care issue Supportive care missing/incorrect which may cause significant harm to the patient Essential care missing such as; antibiotic/GCSF prophylaxis, Allopurinol, Folic Acid Does not include ‘minor’ issues such as antiemetic changes, E45 cream Treatment interval incorrect Treatment planned incorrectly according to protocol and poses a significant risk to the patient Treatment not deferred correctly when patient delayed; resulting in treatment planned for 14 not 21 days. Treatment for day 1 not deferred so that day 8 is on the system but patient is due a delayed day 1

Pharmacy interventions audit cont... Interventions form Pharmacy encouraged to consider completing an incident/audit form

Pharmacy interventions audit cont... Findings of the audit for February Week Week Week Week Prescription numbers Process Issues Minor Errors Significant Errors

Pharmacy interventions audit cont... Not recording drugs given 9913 Deferring errors 5410 Insufficient or no intent 2121 No reason for dose modification 0101 No MUGA result 2023 No dose present 6053 Incorrect dose present Patient not reviewed 1262 Antiemetic error 1110 Supportive care issue 1240 Incorrect drug note 0000 Wrong treatment 1210 Treatment scheduled incorrectly 4110 Week 1 Week 2 Week 3 Week 4 2 others – EDTA requested but not used and old weight used for GFR – 1 significant, 1 minor.

Pharmacy interventions audit cont... Results for February 2010 Week %8.7%7.3%15.9% Week %3.9%10.1%14% Week %9.7% 13.4% Week %7.6%2.6%10.3% Overall5769.4%7.6%7.5%15.1% Prescription numbers Process Issues Minor Errors Significant Errors Total

Pharmacy interventions audit cont... Interesting findings Errors on a Monday are generally higher Confirmations being done on the day 76% confirmed on the Monday not Friday showed 52% error rate (13/25)

Pharmacy interventions audit cont... Interesting findings cont.... Use of entry error Consultant 118.5% Consultant 29% Consultant 35% Consultant 417% Consultant 518% Consultant 631% Consultant 79% Consultant 825% Consultant 920% Consultant 1019% Some numbers are strangely high Training issues? More reason codes required?

Pharmacy interventions audit cont... We accept the system is not perfect There is a recognised flaw in deferring To be fixed in next release Carbo dosing is not straight forward Access to patient record is long winded for from nursing perspective Will improve in next release One size does not fit all With constant monitoring and feedback results can be improved

Pharmacy interventions audit cont... Previous levels of interventions at around % + Currently at % Easier to find issues All relevant information in one place More stringent recording of issues More clearly defined Recording a wider range of interventions Scope for this to reduce further

Future plans ChemoCare version 5.2 in to Test environment on 22 nd March. This includes: ChemoSchedule Diary and Chair management system Big task that will be done at smaller unit first Security matrix Allow mapping of roles with tasks ie. Registrars deleting future treatments Pharmacy module Standardising worksheets and labels Enhanced module is possibility

Questions ?????

More Pharmacy findings cont...