Chemotherapeutic agents are known to have numerous side effects and, due to their potency, can be quite toxic. Exact dosing is critical to ensure that patients receive the benefits needed but without suffering undue harm. Unintentional overdoses of chemotherapeutic agents have resulted in patient deaths. Therefore, extra safety measures must be taken with these drugs.
Changes for Improvement
Allow Chemotherapy Orders Only from Certified Prescribers
Chemotherapeutic agents should be prescribed only by clinicians who have specific training in their use and hazards and who prescribe them routinely. Any organization where chemotherapy drugs are administered should have a credentialing or certification program that clinicians must complete in order to be permitted to prescribe chemotherapy. Staff should accept chemotherapy orders only from these certified clinicians.
- Develop a chemotherapy certification program for your organization in conjunction with the medical staff and pharmacy.
- Require that certified clinicians maintain a certain level of competency, for example via education programs, by prescribing a minimum of chemotherapy per year, etc.
- Provide easy access to the list of certified prescribers to the pharmacy and all patient care units where chemotherapy is administered.
Set Dose Limits for Chemotherapy Drugs
Due their high potency and risk of toxicity, doses of chemotherapy drugs must be exact. An unintentional overdose can result in severe harm, or even death, for the patient. A maximum allowable dose for each chemotherapeutic agent should be set so that a prescriber or person entering an order cannot accidentally select a dose outside the safe range. Each individual dose may appear to be within acceptable safety limits, but the cumulative dose must be considered as well. Remember to set the maximum dose limits not just for each individual dose, but for the amount to be given in 24 hours, during the course of therapy, or over the patient’s total lifetime.
Accept No Verbal Orders for Chemotherapy Drugs
When a verbal or telephone order is given, there is always the chance that the person receiving the order will not hear the order correctly or will misinterpret what is said. If there is any delay between the time the order is given and time it is written or entered into the computer, there is also the risk that the order will not be remembered or entered correctly. With chemotherapeutic drugs, doses must be exact because an unintentional overdose can result in severe harm, or even death, for the patient. Never permit or accept verbal and telephone orders for initial orders or changes when dealing with chemotherapy medications.
Require Peer Consultation and Review for Unusual Orders
Extra safety measures must be in place for administration of chemotherapy drugs because of their high risk of toxicity and other adverse drug events (ADEs) that can be fatal. Dose limits and other restrictions are examples of parameters that health care organizations should place upon these medications. However, in some unusual situations, the patient’s clinical condition may require a variation outside the limits that an organization has set. In such situations, the health care organization should require consultation and review of the request by an approved clinical peer who is another prescriber certified to order chemotherapy. This will ensure that the request is warranted by the patient’s condition and will verify that the order is within a safe range. Ensure that the peer review process will work 24 hours per day and 7 days per week, so that unusual orders cannot "slip through" during off-hours and that the review will not be significantly delayed.
Conduct Independent Double-Checks
Double-checks provide an independent means to verify all information before a medication is administered. Chemotherapy drugs have a very high risk of causing severe adverse drug events due their potency, so an extra safety check to ensure that everything is correct is vital. To be effective, each person checking the medication and information should do so independently. Checking together runs the risk that both people will make the same error (for example, one person reads the dosage incorrectly, and the other person agrees with it, thinking she has heard the correct dose).
- Require that written orders be referenced during the check at the time the dose is prepared and prior to administration.
- Make sure the person performing the independent double-check is another clinical staff member. Patients and families should be involved in patient care, but not part of an independent double-check.
- Consider putting the calculation your hospital or program uses for body surface area (BSA) directly on chemotherapy ordering screens or pre-printed order sheets for easy reference.
Communicate Patient Chemotherapy Information Across Settings
Patients being treated with chemotherapy medications are often receiving care in both the inpatient and outpatient settings over a period of time. Chemotherapy may be administered in either setting, or both. It is important for clinical staff in all settings to record and be aware of what medications and doses the patient has received in each setting so that cumulative dose for a patient can be tracked. Design chemotherapy order sets and medication administration records so that they can follow the patient through both settings.
- Standardize the orders, so that they are the same for all settings whenever possible.
- When calculating cumulative doses, remember to include medication and doses administered in all settings.
Use Chemotherapy Protocols at Point of Care
Protocols help clinicians quickly select appropriate drugs, doses, routes, and other parameters when ordering chemotherapy medications. The protocols can include guidelines about assessments and other clinical interventions that should be followed during chemotherapy administration. Protocols should be available at the point of care so that they can be used for reference by all clinical personnel caring for the patient. The standardized approach of protocols eliminates the chance of many types of error, which can be extremely dangerous with chemotherapy.
Use Computerized Order Sets or Pre-Printed Orders for Chemotherapy Drugs
Chemotherapy drugs can be extremely toxic due to their potency, so minor errors in dosing can lead to severe adverse drug events. Order sets in computerized systems or pre-printed order sheets can be used to list appropriate doses for chemotherapeutic agents, so that prescribers need only "check a box" for the medication and dose desired. Order sets and sheets should only include doses pre-approved by the medical staff and pharmacy, so there is no risk of an unusually high dose being requested by mistake.Include the following:
- Dose in mg/m2
- Body Surface Area (BSA)
- Calculated dose for each administration
- Dose/24 hours
- Dose/course of therapy