Chemotherapy as a Risk Treatment Procedure - Research Paper Example

TABLE OF CONTENT …………………………………………………………………………………… 2 Introduction…………………………………………………………………………………..3 Methodology……………………………………………………………………………….…4 Findings…………………………………………………………………………………….…5 Discussion……………………………………………………………………………………..6 Staffing Related standards………………………………………………………….…..6 Chemotherapy Planning: Chart Documentation standards……………………………7 General Chemotherapy Practice Standards……………………………………….…...8 Chemotherapy Order Standards………………………………………………………..9 Drug Preparation Standards………………………………………………………...…10 Patient Consent and Education………………………………………………………..11 Chemotherapy Administration Standards………………………………………….…..12 Monitoring and Assessment Standard………………………………………….….......12 Conclusion……………………………………………………………………………………..14 Recommendation………………………………………………………………………………14 Works Cited……………………………………………………………………………………15 Appendx1……………………………………………………………………………………….16 Figure 1……………………………………………………………………………………..…….5 Table 1……………………………………………………………………………………….…...4 Table 2…………………………………………………………………………………………....5 Abstract Chemotherapy is a risk treatment procedure that can result into adverse long-term effects if not administered correctly and with precision. Due to increasing safety concerns in oncology, the American Society of Clinical Oncology together with Oncology Nursing Society came up with Chemotherapy Administration Safety Standards that are aimed at minimizing risks and errors in chemotherapy administration. The safety standards that were formulated include: Staffing-related, Chemotherapy Planning: Chart Documentation, General Chemotherapy Practices, Chemotherapy Order standards, Drug preparation, Patient consent and education, Chemotherapy administration, and Monitoring and Assessment standards. The Alfred Health Department of Haematology and Oncology day Care Unit observed the need to reduce the occurrence of and minimize risk of errors while increasing efficiency of services to its chemotherapy patients. With regard to this need, the day care unit decided to conduct a survey to evaluate if the practice is in compliance with ASCO/ONS Chemotherapy Administration Safety Standards. The researcher captured data by recording the responses of participants that were mostly ‘yes’ and ‘no’ together with short comments with regard to each standard. The findings were recorded, discussed and evaluated accordingly. After the survey it was discovered that the unit was in compliance with five of the eight ASCO/ONS Chemotherapy Administration Safety Standards. Owing to this, the survey came up with three recommendations that the unit must adhere to and implement them effectively in order to fully comply with chemotherapy administration safety standards Evaluating Compliance of Chemotherapy Administration Safety Standards of practice in an oncology day centre Introduction The Alfred Health Department of Haematology and Oncology realized that there was need to come up with safety strategies that would result into minimizing the occurrence of and reduction of the risk of errors while increasing efficiency of service to its patients. Consequently, the Oncology department recognized that there were no accessible safety standards that could assist in assessing chemotherapy administration safety. Owing to these facts, the Hospital decided to conduct a survey using the American Society of Clinical Oncology (ASCO) and Oncology Nursing Society (ONS) standards that were formulated in 2008. These standards were created to assist in the administration of chemotherapy to adult patients in the outpatient setting. The hospital came up with various tools to audit techniques basing on ASCO/ONS standards. The main objective of this research report is evaluating the compliance with chemotherapy standards of practice in the Alfred Health Department of Haematology and Oncology day care center using the American Society of Clinical Oncology and Oncology Nursing Society chemotherapy administration standards. The report will discuss the methodology used in collecting data, present the findings, discuss the findings, and give a conclusion and recommendations. Methodology The researcher adopted multidisciplinary tools developed by the ASCO/ONS Chemotherapy Administration Safety Standards (Jacobson et al, 1). The Alfred Health Department of Haematology and Oncology day care center cared for approximately 30 oncology patients per day with 15 chairs and 5 bays for bed. The study was conducted in July 2010, where the sample population was 8 participants that included medical oncologists, nurses, and a pharmacist. There are eight ASCO/ONS Chemotherapy Administration Safety Standards including; Staffing Related standards, Chemotherapy Planning: Chart Documentation Standards, General chemotherapy Practice Standards, Chemotherapy Order Standards, Drug Preparation Standards, Patient Consent and education Standards, Chemotherapy Administration Standards, and Monitoring Assessment Standards (Jacobson et al, 2). Additionally, there are 31 categories of evaluations that are listed under these 8 standards; these standards were discussed with each and every participant. The researcher captured data by recording the responses of participants that were mostly ‘yes’ and ‘no’ together with short comments with regard to each standard. Table 1: ASCO/ONS Chemotherapy Standards of Practice 1 Staffing-Related Standards 2 Chemotherapy Planning: Chart Documentation Standards 3 General Chemotherapy Practice Standards 4 Chemotherapy Order Standards 5 Drug Preparation Standards 6 Patient Consent and Education Standards 7 Chemotherapy Administration Standards 8 Monitoring and Assessment Standards (Appendix 1) Findings The results of complete compliance to the Chemotherapy Administration Safety Standards in the Alfred Health Department of Haematology and Oncology day care center were documented with Chart Documentation, Drug preparation, Patient consent and monitoring and assessment education, Chemotherapy administration and Monitoring and Assessment. See figure 1 below. Figure 1 Number of Categories belonging to the eight chemotherapy administration and safety standards which are compliant or non-compliant. (Appendix 1) From figure 1 above, non-compliance was documented with Staffing related standards; Chemotherapy orders standards; and General Chemotherapy practice standards. Table 2: Non-Compliant Standards documented at the Alfred Health Department of Haematology and Oncology day care center. Standard Non-Compliance Staffing Related Monitoring Chemotherapy administration competency at specified intervals Chemotherapy Orders Maintaining and use of standardized, regiment level, preprinted or electronic forms for chemotherapy prescription and charting the cumulative lifetime dose General Chemotherapy practice Policy in place for how informed consent was obtained from patients Discussion According to the survey conducted in July 2010 and completed by oncology nurses/oncology/medical oncologists/oncology pharmacist evaluating the compliance with ASCO/ONS chemotherapy administration safety standards; it was found out that the day care unit complied with five out eight standards while three received non-compliance. These standards and there levels of compliance are discussed as follows: Staffing Related Standards According to the Journal of Clinical Oncology, the ASCO/ONS chemotherapy Administration Safety Standards, states that, any practice must have procedures, policies, and guidelines for verification of training and continuing education for clinical staff (Jacobson et al, 3). Given this requirement, the day care unit had in place an excellent education and orientation program for the nursing staff. The medical staff receives medical training based on the medical training requirements. Additionally, a credentialing program for accrediting pharmacists is available at the oncology day care unit. Through the survey it was also established that the day care center has qualified and specialized medical oncologists and oncology registrars who are tasked with writing, signing and documenting orders for parenteral and oral Chemotherapy as it is required by practice guidelines, procedures and policies (Jacobson et al, 4). In the same line of evidence, the study exposed that the day care unit has a team of specialized oncology pharmacists to prepare drugs for both oral and parenteral chemotherapy. The study noted that all nurses administering chemotherapy at the day care unit are experienced nurses with exceptional chemotherapy learning qualifications approved by the competency assessment department. According to the JCO, ASCO/ONS Chemotherapy Administration Safety Standards, demands that, only qualified physicians, physician assistants, advanced practice nurses or registered nurses to be allowed to administer chemotherapy (Jacobson et al, 5). During the study it was concealed that all clinical staff at the day care unit maintained current certification in basic life support as required by the ASCO/ONS Chemotherapy Administration Safety standards. However, it was found out that the day care unit was yet to develop standard mechanisms for monitoring chemotherapy administration competency at specified intervals to fully comply with the staffing-related Chemotherapy Administration Safety Standards (Jacobson et al, 6). Owing to these findings, The Alfred Health Department of Haematology and Oncology day care unit has not completely complied with the ASCO/ONS staffing-related standards. Chemotherapy Planning: Chart Documentation Standards According to ASCO/ONS Chemotherapy Administration Safety Standards dictates that before prescribing a new chemotherapy regimen there should be various documentations available to the prescriber (Jacobson et al, 7). In accordance with these requirements, The Alfred Health Department of Haematology and Oncology day care unit has in place the pathological verification of initial diagnosis to ensure drugs prescriptions are inline with the diagnosis. The documentation chart also indicates the initial and current cancer status of the patient. It was also deduced that full medical history and other physician examinations including minimum weight, height, and organ-specific assessment are conducted and recorded prior to prescription of any regimen. The survey revealed that, during chemotherapy planning the unit investigates and records the presence of any hypersensitive reactions and allergies that the patient has before administering the treatment. Accordingly, the pharmacist completed the medication forms for all patients to fully make the patients comprehend the medication regimens. He/she provided information with regard to the ailment and the need for self-care. In the same line of revelations, the study established the hospital evaluated patients regarding their psychosocial needs for support (Jacobson et al, 8). Nonetheless, MDT meetings together with clinical notes for patients were the baseline on which chemotherapy treatment planning was derived; for instance the objectives of the treatment, chemotherapy drugs, treatment duration and the doses were primarily obtained from patient clinical notes (Jacobson et al, 9). The Alfred Health Department of Haematology and Oncology day care unit has a comprehensive patient education and follow up program that are undertaken by the unit pharmacists; this was basically devised for oral chemotherapy where patients have frequent office visits that are essential for monitoring their treatment as defined in the treatment plan. General Chemotherapy Practice Standards The Alfred Health Department of Haematology and Oncology day care unit has an evidence based medication plan; for instance there are defined standards for chemotherapy regimens and diagnosis references that are readily provided for. The research ascertained that the unit used eViQ as a primary source for chemotherapy regimens. Furthermore, for orders that were found to vary from standard regimens, the specialized staff at the oncology unit provided supporting references before they are administered. They provided reasons for dose modification which were then properly and safely documented (Jacobson et al, 10). The study noted that The Alfred Health Department of Haematology and Oncology day care unit maintained written statements that determined suitable time intervals for specific regimen laboratory tests. These tests were evidence based in accordance with the existing national guidelines. However, the research found out that The Alfred Health Department of Haematology and Oncology day care unit does not have a policy that provided guidelines on how to obtain informed consent from patients (Jacobson et al, 11). Nevertheless, the unit obtained and documented informed consent in the patient report. The unit did not administer chemotherapy prepared away from the site and did not have a policy for quality control of such practices. From this discussion, it is evident that The Alfred Health Department of Haematology and Oncology day care unit has not fully complied with the General Chemotherapy Practice Standards. Chemotherapy Order Standards The Alfred Health Department of Haematology and Oncology day care unit did not permit verbal orders except to hold or stop administration of chemotherapy. In this regard, new orders or changes to orders were made in writing prior to any new chemotherapy administration. Further, The Alfred Health Department of Haematology and Oncology day care unit did not maintain nor used standardized regimen-level, pre-printed electronic forms for writing chemotherapy prescriptions. However, the pharmacy ensured and monitored all medications prescribed using generic names; the abbreviation policy was followed at the unit (Jacobson et al, 12). According ASCO/ONS, order forms should and must list of chemotherapy agents in the regimen together with their dosing parameters; it is also a must for all medications within a given order set to be written using full generic names while also following the Joint Commission Standards with regard to abbreviations (Jacobson et al, 13). The Alfred Health Department of Haematology and Oncology day care unit had a system in place that ensured complete orders. For this matter, the orders had full patient’s name together with a second patient identifier such as patient’s medical record number and DOB. Consequently, the order had date, protocol name and number, the regimen name and cycle number were also provided. The day care unit had an appropriate criterion for treatment as it based on laboratory results and toxicities. The complete orders included patient’s allergies. The unit used standard calculation methodology for doses; for instance BSA m2 was used for calculating creatinine clearance. Accordingly, the weights, height, together with any other variables were used in calculating patient’s dose. The order document also comprised the dose with its cumulative lifetime as it was the unit’s protocol (Jacobson et al, 14). Appropriate supportive care treatments for the regimen were offered at the day care center. There was a sequence in administration of drugs. The hospital did not pre-order for parenteral/oral chemotherapy. Drug Preparation Standards With regard to ASCO/ONS Chemotherapy Administration Safety Standards, states that a second person qualified and approved by the practice can prepare and administer chemotherapy; he/she can independently verify and evaluate each chemotherapy order prior to preparation and confirmation of the administration. Through the study, it was found out that the day care center had oncology pharmacists who undertook special order preparations in pharmacy before they were administered. For instance; two patient identifiers were used, drug names on each order included, drug dose, volume, rate and route of administration were determined (Jacobson et al, 15). The dosing calculation was comprehensively done where all variables used in the calculation were indicated; furthermore drugs for chemotherapy were appropriately labeled once they were prepared. In addition, full generic names were written on the orders and the administration route and doses were given (Jacobson et al, 16). A fully prepared order also indicated the total volume of the dose to be administered and on which date. Consequently, the preparation and expiration date of the constituted drugs were also indicated. The Alfred Health Department of Haematology and Oncology day care unit had a policy that dictated that intrathecal medication would not be prepared at the same time with any other agents. Nonetheless, the unit stored intrathecal medications in uniquely isolated location in well labeled containers for easy identification. It was also concealed that the unit could only deliver intrathecal medication to the patient with other medication only if the medication was meant for the central nervous system (Jacobson et al, 17). Patient Consent and Education According to the study it was revealed that at the day care unit each patient was given a written document having his/her diagnosis before commencing on chemotherapy. The goals of the treatment were well stipulated in the document; a length discussion with the patient was held regarding his/her diagnosis where choices of treatment and goals of treatment were well explained. In this regard, the duration of chemotherapy was planned. The unit gave the patient information regarding possible long-term adverse effects of the treatment. For instance, risks associated with specific drugs, symptoms that require notification and emergency contact information were also discussed (Jacobson et al, 18). The unit also had a plan for follow up and monitoring. The chemotherapy physicians at the unit documented the informed patient consent for chemotherapy before administering chemotherapy. Oncology physicians and oncology pharmacists provided both written and electronic education materials on oral chemotherapy particularly to patients prescribed for oral chemotherapy before or during prescription (Jacobson et al, 19). The patient education entailed procedures for preparation, administration and disposal of oral chemotherapy (Jacobson et al, 20). The plan for the patient education included family members of the patient, and caregivers with regard to the ability of the patient to take the responsibility of therapy management. Chemotherapy Administration Standards It was established that at the day care unit two or more qualified oncology personnel prior to administering chemotherapy, verified and evaluated patient identifications using more than two identifiers like the UR number and/or DOB. They together with the patient confirmed the planned treatment including the drug route and subsequent symptom management. Accordingly, the oncology personnel verified and determined the accuracy of dug name, dose, volume, administration rate and route (Jacobson et al, 21). The drug’s expiration times and the physical integrity and appearance of the drugs were also determined. The oncology personnel and the patient signed in record or electronically to fully indicate that indeed the verification was done. The two signatures on the chemotherapy administration document wholly approved the verification. It was also noted that the unit has extravasation management procedures; for example, antidote order sets were well defined, available and accessible. The unit had an independent qualified practitioner on the site and who was always available during all chemotherapy administrations (Jacobson et al, 22). Monitoring and Assessment Standards The Alfred Health Department of Haematology and Oncology day care unit had a response protocol for life-threatening emergencies for patient support that went beyond basic life support. The medical and nursing staff at the day care unit assessed and documented any changes in clinical status and weight of the patient during each clinical visit and during chemotherapy administration. The medical staffs were tasked with recording any performance changes that the patient exhibited. Additionally, the research established that the medical and nursing staffs at the unit recorded patient previous reactions, allergies and treatment related toxicities (Jacobson et al, 24). Consequently, they also recorded the psychological concerns and need for support for patients. On the other hand, the pharmacy and medical staff at every clinical visit and during administration of chemotherapy, they assessed and documented patient’s current medications. They also reviewed any changes with regard to patient medication in the same visit. The survey also found out that the unit maintained a referral list for supportive care services including psychological support. The oncology staffs at the unit have established procedures for both documentation and follow-up procedures particularly for those patients who absconded treatment and office visits (Jacobson et al, 25). The study revealed that the unit used WHO toxicity scoring baseline to evaluate and document toxicities related to the treatment. The day care center had policies in place for identifying toxicities; for instance practitioners at the unit provided a 24/7 triage which cared for toxicities. The policy at the unit demanded for consistent communication and documentation of toxicities across the unit (Jacobson et al, 26). The research exposed that the unit assessed and documented toxicities which were then used for planning subsequent treatment cycles. Procedures for tracking cumulative doses with regard to agents of chemotherapy associated with cumulative toxicity risk were well established at the unit. Standard processes for specific diseases were used to monitor treatment responses. These standards were based on documented literature or practice determined. The Alfred Health Department of Haematology and Oncology day care unit had risk and incident management system that helped in risk-free reporting of errors. The unit also reviewed errors and near-miss reports twice per year (Jacobson et al, 27). Conclusion Given the discussion above, it was evidence that the day care unit had complied fully with five ASCO/ONS Chemotherapy Administration Safety Standards, that is; Chemotherapy Planning: Chart Documentation Standards, Drug Preparation standards, Patient Consent and Education Standards, Chemotherapy Administration Standards, and Monitoring and Assessment Standards. However, the Alfred Health Department of Haematology and Oncology day care had not fully complied with Staffing Related Standards, General Chemotherapy Practice Standards and Chemotherapy Order Standards. This was mainly, because the staff had no standard mechanism for monitoring chemotherapy administration competency at defined levels. With regard to Chemotherapy order standards, the Hospital never maintained nor used standardized regimen-level, pre-printed or electronic forms for chemotherapy prescription writing. Consequently, the cumulative lifetime dose was not charted. Lastly, the General Chemotherapy Practice standards; the day care unit did not have a policy dictating how informed consent was obtained from the patient despite the fact that the consent was routinely obtained and documented in the patient’s record. Recommendations 1. The unit should develop a standard mechanism for monitoring chemotherapy administration competency at specified intervals 2. The day care center must maintain and use standardized, regimen-level, pre-printed or electronic forms for chemotherapy prescription writing and they should also come up with a mechanism for charting the cumulative lifetime of doses 3. The unit should and must formulate a policy that will dictate how to obtain an informed consent from patients. Works Cited Jacobson O. Joseph, Polovich Martha, McNiff K. Kristen, LeFebvre B. Kristine, Cummings Charmaine, Galioto Michele, Bonelli R. Katherine, and McCorkle R. Michele. American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards. Journal of Clinical Oncology. November 2009. Retrieved on 24/08/2012, from; http://www.asco.org/ASCOv2/Practice+%26+Guidelines/Quality+Care/Quality+Measurement+%26+Improvement/ASCO/ONS+Standards+for+Safe+Chemotherapy+Administration+%5B2011%5D Appendix 1 Read More