Safe Implementation of Computerized Provider Order Entry for Adult Oncology

Abstract

SummaryBackground: Oncology has lagged in CPOE adoption due to the narrow therapeutic index of chemotherapy drugs, individualized dosing based on weight and height, regimen complexity, and workflows that include hard stops where safety checks are performed and documented. Objectives: We sought to establish CPOE for chemotherapy ordering and administration in an academic teaching institution using a commercially available CPOE system. Methods: A commercially available CPOE system was implemented throughout the hospital. A multidisciplinary team identified key safety gaps that required the development of a customized complex order display and a verification documentation workflow. Staff reported safety events were monitored for two years and compared to the year prior to go live. Results: A workflow was enabled to capture real-time provider verification status during the time from ordering to the administration of chemotherapy. A customized display system was embedded in the EMR to provide a single screen view of the relevant parameters of chemotherapy doses including current and previous patient measurements of height and weight, dose adjustments, provider verifications, prior chemotherapy regimens, and a synopsis of the standard regimen for reference. Our system went live with 127 chemotherapy plans and has been expanded to 189. Staff reported safety events decreased following implementation, particularly in the area of prescribing and transcribing by the second year of use. Conclusions: We observed reduced staff reported safety events following implementation of CPOE for inpatient chemotherapy using an electronic verification workflow and an embedded custom clinical decision support page. This implementation demonstrates that CPOE can be safely used for inpatient chemotherapy, even in an extremely complex environment.

Medication safety incidents in paediatric oncology after electronic medication management system implementation

“…For example, errors in the configuration of prescribing templates may be 'automatically incorporated into otherwise error-free prescriptions' (Aita et al, 2013). Comprehensive EMM systems for chemotherapy protocols are challenging to implement, both in adult and paediatric settings (Martin, Kaemingk, Frieze, Hendrie, & Payne, 2015;Whalen et al, 2018). They require time-dependent, patient-specific dosing functions based on factors such as age, weight and surface area (highly variable over a child's course of treatment), organ function, as well as functionalities for scheduling and timing of interdependent medications and supportive care.…”

“…They require time-dependent, patient-specific dosing functions based on factors such as age, weight and surface area (highly variable over a child's course of treatment), organ function, as well as functionalities for scheduling and timing of interdependent medications and supportive care. The systems must address critical workflow functionalities, such as dual/multiple authorisations and checks of orders by an oncologist and verified by a pharmacist and two nurses (Martin et al, 2015). After implementation, EMM systems need maintenance and updating to address changes in work practices and in chemotherapy protocols (Chen & Lehmann, 2011).…”

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review

“…Another study evaluated duplicate checks in a non-chemotherapy setting [ 19 ]. Two studies did not mention total number of prescriptions, and we were unable to retrieve the data by correspondence with the authors [ 20 , 21 ]. Two studies were comparative prospective parallel studies [ 22 , 23 ].…”

Design, implementation, and evaluation of a CPOE system in a cancer care setting: A case study on the gastric cancer patients

“…These include the integration of CPOE systems with patients' electronic records, the involvement of key stakeholders (oncologists, clinical pharmacists, nurses, and the system design and implementation team) from the early stages of system design and development, the training of users, and developing the required skills for appropriate use of the systems. [ 19 27 35 ]…”