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