Clinical Safety

1
Clinical Safety Effectiveness
Improvement of Chemotherapy Order Preparation
Process to Improve Patient Safety in the Gyn Onc
Center
DATE
2
The Team

• Team Members
• Judith Smith, Pharm.D., BCOP, FCCP, FISOPP
  Associate
  Professor, Department of Gynecologic Oncology and
  Reproductive Medicine, Division of Surgery
• Tracy Spinks, B.B.A.
  Project Director, Institute
  for Cancer Care Excellence
• Elizabeth Garcia, RN, MPA
  
  Clinical Administrative Director, Gynecologic
  Oncology Center
• Facilitator
• Russell Content, MBA
  
  Clinical Business Manager, Gynecologic
  Oncology Center
• Sponsor
• Charles Levenback, M.D.
  
  Professor Deputy Chair, Department of
  Gynecologic Oncology and Reproductive Medicine,
  Division of Surgery
  
  Medical Director, Gynecologic Oncology Center

3
Our Why

• 37 year old female
• Mother of two girls
• 2 weeks post partum
• Curable cancer
• Admitted for Bleomycin, Etoposide, Cisplatin
  (BEP)

4
Our Why

• Orders prepared, reviewed signed off
• Advance Practice Nurse
• Fellow
• Attending
• Orders dispensed
• Two pharmacists checked
• Orders Administered
• Two Registered Nurses
• Patient Rounded on daily
• Advance Practice Nurse
• Clinical Pharmacist
• Fellow
• Attending

5
Our Why

• Orders prepared, reviewed signed off
• Advance Practice Nurse
• Fellow
• Attending
• Orders dispensed
• Two pharmacists checked
• Orders administered
• Two Registered Nurses
• Patient rounded on daily
• Advance Practice Nurse
• Clinical Pharmacist
• Fellow
• Attending

• Cisplatin dose was a 4x overdose
• Suppose to be 20 mg/m2 x 5 days
• Written 75 mg/m2 x 5 days
• Error was not caught until Day 5 just prior to
  last scheduled dose

6
Our Why

• Orders prepared, reviewed signed off
• Advance Practice Nurse
• Fellow
• Attending
• Orders dispensed
• Two pharmacists checked
• Orders administered
• Two Registered Nurses
• Patient rounded on daily
• Advance Practice Nurse
• Clinical Pharmacist
• Fellow
• Attending

• Cisplatin dose was a 4x overdose
• Suppose to be 20 mg/m2 x 5 days
• Written 75 mg/m2 x 5 days
• Error was not caught until Day 5 just prior to
  last scheduled dose

• Patient HARM
• Acute renal toxicity
• Plasma pheresis hospital admission x 10 days
• Permanent hearing loss

7
We have a problem. .it is time for change.
8
Timeline
Chemo Labs check box, ATC scheduling 3hr block
Independent second check education Chemotherapy
Standard Doses references database
On Call Schedule Updated Patient Safety
Lectures Chemotherapy Competency Launched
Sentinel Event 1/16/2010
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What are we trying to accomplish?
Improve patient safety when receiving
chemotherapy
No chemotherapy errors reaching our patients
10
What are we trying to accomplish?
Improve patient safety when receiving chemotherapy

• Aim statement
• To decrease the number of gynecologic oncology
  chemotherapy order set clarifications by 20 by
  July 2011.
• Rationale
• Decreasing chemotherapy order set clarifications
  will reduce the likelihood of a chemotherapy
  error reaching the patient ? Get it right the
  first time.
• Business Case
• To decrease associated financial and emotional
  costs with chemotherapy error reaching patient.

10
11
Process Analysis
12
Process Analysis
CSE Focus
13
Process Analysis
14
Process Analysis
15
Process Analysis
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CSE InterventionGoal Labs results available
for chemotherapy order process

• Patient Education
• Signage in Gyn Onc Center Lobby
• Got labs? button
• Updated "Tips for Convenience"
• Provider Education Resources
• Education reminder to order labs
• Prompt on order form to order labs with
  chemotherapy

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CSE InterventionsGoal Increase consistency and
reduce information overload

• Chemotherapy Education
• Chemotherapy Education Checklist
• Documenting on 1st cycle Chemotherapy teaching
  provided see IPOCTR under interventions
• Chemotherapy Preparation
• Chemotherapy Order Checklist
• Accountability reports

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Order set clarificationsWhat we measured

• Measures
• Process Percentage of chemotherapy order sets
  with clarifications
• Efficiency Chemotherapy order processing time
• Create to Accept
• Create to verify
• Verify to Attending sign
• Time was based on 12-hour workday
• Excluded any clarification beyond 20 days from
  time created

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Order set clarificationsWhat we measured

• Data source
• EMR reports
• ONLY included chemotherapy order sets
• Only clarifications that were drug-related
• Four twelve-week periods
• Baseline - 10/26/2009 - 01/15/2010
• First Interventions - 03/08/2010 - 05/28/2010
• Second Interventions - 10/18/2010 - 01/07/2011
• Third (CSE) Interventions - 03/21/2011 -
  06/10/2011

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Chemotherapy Clarifications by PeriodP-Chart
Sentinel Event 01/16/2010
CSE Interventions 03/21/2011
UCL.16
CL.14
UCL.12
LCL.11
CL.09
LCL.06
Baseline10/26/2009 01/15/2010
First Interventions 03/08/2010 - 05/28/2010
Second Interventions 10/18/2010 - 01/07/2011
CSE Interventions 03/21/2011 - 06/10/2011
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Chemotherapy Clarifications in context of clinic
volume
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Chemotherapy Clarifications in context of clinic
volume
49 decrease from the Baseline period to the CSE
intervention period.
23
Time Assessment Create to Accept (in
Hours)Inside and Outside Clinic Hours
Third (CSE) Interventions - 03/21/2011 -
06/10/2011
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Its not a matter of rushing..Time assessment
PRIOR to order being sent to ATC Pharmacy

• Orders Without Clarifications
• Baseline
• Create to Verify 14 minutes
• Verify to Signed 25 minutes
• TOTAL 39 minutes
• Orders Without Clarifications
• CSE Interventions
• Create to Verify 15 minutes
• Verify to Signed 15 minutes
• TOTAL 30 minutes

• Orders With Clarifications
• Baseline
• Create to Verify 16 minutes
• Verify to Signed 22 minutes
• TOTAL 38 minutes
• Orders With Clarifications
• CSE Interventions
• Create to Verify 14 minutes
• Verify to Signed 15 minutes
• TOTAL 29 minutes

p gt 0.05, NS
p gt 0.05, NS
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Annual Time Assessment for Chemotherapy Order
Clarifications
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Return on Investment
27
Return on Investment
Equals 167 saved per chemotherapy order
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Lessons Learned

• Educational interventions reduced number of
  clarifications
• It was not a matter of time spent on order
  preparation
• Data does not support rationale that rushing
  contributing factor
• Times of day with limited resources increases
  risk for clarifications/errors

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Next steps
30
Next steps

• In Department Gynecologic Oncology
• Faculty complete chemotherapy competency
• Develop annual re-assessment tool
• Develop specific assessment tool for level III
• Define set hours for writing chemotherapy orders
• Between 8 AM to 5 PM
• Monday Friday
• At Institutional Level
• Proposal being considered for implementation
• Chemotherapy competency
• Restricting hours for writing elective/non-emergen
  t chemotherapy orders

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AcknowledgementsTeam of Stakeholders

• Physicians
• Shannon Westin, M.D., MPH
• Larissa Meyer, M.D. , MPH
• Judith Wolf, M.D.
• Pharmacists
• Benjamin Yee, RPh
• Ginger Langley, Pharm.D., BCPS, CPHQ
• Patient Advocate
• Ashley Dubbelde, B.A.A.S.

• Nursing
• Kimberly Burns, RN, WHNP
• Sandy Knight, RN, CPON
• Donna Branham, RN
• EMR Development Support
• Karl Jonsson, B.S.
• Business Center
• Linda Beardon, RN, CHAM
• Administrative Support
• Marisa Ortega, CPS
• Dana Hedge

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Patient Safety

• chemotherapy safety putting together the pieces
  of the puzzle.

Thank you! jasmith_at_mdanderson.org