In 2012, both the United States (US) and Canadian subsidiaries of the Institute for Safe Medication Practices (ISMP) collaborated on the development of a self-assessment specific to the evaluation of safe practices in oncology settings and the identification of opportunities for improvement.
The tool consisted of 175 items depicting ten key overall domains.1 An international sample of hospital, clinic, and office settings were invited to complete this self-assessment with the intent to provide a “snapshot” of the use of existing safeguards and to delineate areas for safety improvements within oncology. An online portal provided participating organizations the opportunity to post and compare their findings with others. A total of 352 organizations from 13 countries submitted results. Findings revealed an interesting composite of the global state of medication safety practices within oncology settings.2
At least 90% of respondents reported the following items to be fully implemented in their settings, representing the highest scores for safety practice implementation (they are cited below by their rankings – highest first):
Oral and parenteral chemotherapy doses, biotherapy, and treatment-related drugs are expressed by metric weight or activity units only (e.g., mg, units) not by volume (e.g., ml, teaspoon) or number of dosage forms (e.g., tablets, vials);
Intravenous push chemotherapy/biotherapy drugs that are known vesicants are administered through a side arm port on the intravenous tubing while a compatible base solution is infusing;
Guidelines and kits (including personal protective equipment (PPE) for chemotherapy/biotherapy spills are readily available for immediate use;
Chemotherapy/biotherapy (both oral and parenteral) is always hand delivered;
Infusion pumps/controlled rate devices are used for the administration of all intermittent intravenous infusions and continuous intravenous solutions containing chemotherapy/biotherapy;
All areas where chemotherapy/biotherapy is prepared are under the control of pharmacy or have pharmacy oversight;
A biological safety cabinet/isolator, certified by qualified personnel annually or as required by governing bodies, and PPE are used when preparing chemotherapy/biotherapy;
All chemotherapy/biotherapy and treatment-related drugs that are administered to patients are prepared/mixed on site or are provided directly to the facility by an accredited chemotherapy compounding facility;
Commercially available standard base solutions are used for chemotherapy/biotherapy preparation not compounded by the facility;
Chemotherapy/biotherapy drugs are purchased from authorized distributors or manufacturers who can verify the source of the drug.
Ten of the 175 items had been fully implemented by 25% or fewer respondents representing the lowest scores in the overall assessment and hence representing the greatest areas for improvement. Eight were specific to oncology practice (the other two addressed bar coding and electronic interfacing of medication orders with laboratory systems). The eight items having the most room for safety enhancements (from highest to lowest ranking) included:
A process is in place for a designated person to routinely test the computer system to ensure that maximum dose alerts are present for chemotherapy, biotherapy, and treatment-related drugs and build hard stops that cannot be overridden;
An established interdisciplinary oncology team, that includes frontline staff, reviews the chemotherapy/biotherapy medication use process at least annually (e.g., using a proactive risk assessment tool such as this self-assessment) to identify potential risk factors for medication errors;
A structured process is in place for environmental monitoring for chemotherapy/biotherapy contamination in all areas of preparation and administration;
The computer system performs dose-range checks and warns prescribers, pharmacists, and nurses about under-doses for all chemotherapy, biotherapy, and treatment-related drugs;
The computer system dose-range checking feature can be modified to recognize protocol-specific dosing ranges;
The distal ends of all tubing are clearly labelled with the route of administration for patients who are receiving chemotherapy/biotherapy and other treatments via various routes (e.g., bladder, intravenous, central venous, arterial);
The distal ends of all tubing on all chemotherapy/biotherapy infusions are clearly labeled as containing chemotherapy/biotherapy;
When multiple chemotherapy/biotherapy infusions are being administered intravenously, the distal ends of all tubing are clearly labeled with the drug name.
Other key findings have relevance to medical oncology practice settings. Namely that,
Nearly 46% of the US respondents reported that they did not adhere to the 2007 World Health Organization recommendation that vincristine (and other alkaloids) be prepared and administered in minibags;
Less than half of all respondents (43.5%) indicated that they had fully implemented safety-related processes for oral chemotherapy orders similar to those for parenteral chemotherapy;
Nearly one-half of US respondents reported having fully implemented an annual competency reassessment process for those involved in chemotherapy admixing and administration;
Patient education practices were assessed specific to offering information about side effects and when to seek help; overall, only 38.9% of respondents stated that they assessed the patient and/or family’s comprehension of information and instruction.
The pursuit of safety within cancer care should be a relentless, ongoing initiative composed of a multidisciplinary effort whose intent is improving practice in a proactive manner. Readers may be interested in accessing the self-report of medication safety described in this blog.3
Institute for Safe Medication Practices. MEDSAFE Annual Conference 2012. 2012 Oct 4.
Greenall J, Shastay A, Vaida AJ, et al. Establishing an international baseline for medication safety in oncology: Findings from the 2012 ISMP International Medication Safety Self-Assessment for Oncology. J Oncol Pharm Pract. 2015 Feb;21(1):26-35.
2012 ISMP International Medication Safety Self Assessment® for Oncology: https://mssa.ismp-canada.org/oncology.
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