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Hospital Implements New Oral Chemotherapy Handling Process in Effort to Increase Safety

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ANAHEIM—A new process for handling oral chemotherapy medications that delineates prescriber privileges may help to avert errors or drug–drug interactions, said Brian L’Heureux, PharmD, at the 45th Midyear Clinical Meeting of the American Society of Health-System Pharmacists. 

On August 1, 2010, at Suburban Hospital in Bethesda, Maryland, a new procedure for processing oncology orders was implemented, said L’Heureux, an oncology pharmacy resident. 

Under the new system, oncology-specific medications have to be ordered by prescribers with delineated privileges using a specific chemotherapy order form. 

In explaining the need for the new process, he said that most outpatient oral chemotherapy medications were continued by admitting physicians who were unfamiliar with them. “Therefore, they were prescribing medications for which they didn’t necessarily know all of the ins and outs, and this was particularly true of oral chemotherapy,” he said. 

More important, oral chemotherapy medications were being improperly handled by nurses on patient care units who were not chemotherapy certified. 

The new process did allow for some exceptions for ordering medications that can also be used outside of oncology, such as methotrexate and hydroxyurea, for nonchemotherapy indications. 

L’Heureux and colleagues conducted a medical use evaluation for the immediate 2 months following implementation of the new process for handling oral chemotherapy medications. Daily reports were generated through the pharmacy computer system, searching for formulary and nonformulary oral chemotherapy. Concurrent chart reviews were performed on all patients receiving oral chemotherapy. 

The data collected included drug name, drug class, indication, the name of the prescriber and whether the prescriber had delineated privileges to write chemotherapy orders, the person transcribing the order to the chemotherapy order form, any major drug–drug interactions that required intervention, and whether certified chemotherapy nurses administered the medication. 

“A big part was whether chemotherapy nurses were actually administering the medication. Previously, on admission, if the prescribing doctor didn’t write that it’s chemotherapy, and the drug is continued, the nurses would not necessarily know that the [continued] drug is a chemotherapy medication,” he said. “When it was entered into our computer system, it came across as patients on medication, so there weren’t a lot of flags telling the nurses.” 

Twenty-six oral chemotherapy orders were reviewed over the 2-month period. Seventy percent of the orders were written by physicians with delineated privileges and 23 orders were written on the appropriate form, of which 17 were transcribed by the pharmacist. 

The prescribing physicians were hospitalists 46% of the time, hematologists/oncologists 23% of the time, and intensivists 8% of the time. 

“With this information, we progressed to better delineated privileges to finalize who was allowed to prescribe which drugs,” said L’Heureux. 

Eight drug–drug interactions were identified during chart review; of these, one was intervened upon at the time of the chemotherapy order. 

“In the Pyxus automated dispensing machines that we use, there are alerts for an oncology nurse to come down and give the medication, but we found that many times, nurses weren’t alerted to come down and administer it,” he said. During the 2 months of the oral chemotherapy review, only 70% of chemotherapy orders were administered by chemotherapy-certified nurses.


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