Improving Chemotherapy Delivery* and Transfusion Safety

1. Improving Chemotherapy Delivery* and Transfusion Safety Vanderbilt University Medical Center *BlueCross BlueShield of Tennessee October 2, 2001

2. Motivation • Institute of Medicine (IOM) report - Nov 1999 • IOM Recommendations • “Establishment of voluntary reporting system to collect information on errors that cause minimal or no harm” • Build a culture of safety

3. Why Do Errors Occur? • Complexity – how much info can our minds process? • Hand-offs and and shift changes • Verbal and written communications • Look-alikes and sound-alikes • Stressful situations/Understaffing • Poor system designs and unsafe situations • We are human!

4. Patient Safety at VUMC • Blood Transfusion Safety • MRI Safety • Westchester Medical Center, Valhalla, NY • Chemotherapy Delivery • Dana Farber Cancer Institute, Boston

5. Transfusion Safety • Major Processes of Transfusion System • Ordering blood (Verbal, written, order entry) • Handling/Storage of blood • Transfusion of product into patient • Safety Concerns • Communications • Patient identification (Patient-product match) • Workload/Stress • Blood handling

6. Chemotherapy Project Overview • Project Aim • Guarantee safe and appropriate chemotherapy delivery to each and every pediatric oncology patient • Outcomes Focus • To eliminate adverse drug events (ADEs) / outcomes associated with variation chemotherapy delivery • Process Focus • Improve the system processes for prescribing, processing, and administration of chemotherapy.

7. Metrics - Across Chemo Delivery Prescriptions - Physician Processing - Pharmacy Administration - Nursing

8. Metrics - Chemo Delivery Processes Prescribing Processing Administration Correct Drug Correct Dose Correct Route Correct Schedule Omission Allergy Contra Indications Monitoring Patient in need

9. Errors and “Near Misses”

10. Reducing Chemo Errors • Certified healthcare providers only (Onc/chemo) • Verify the dose via dose-verification process • Establish dosage limits • Standardize the prescribing vocabulary • Work with drug manufacturers – improve labeling safety • Educate the patients about their chemo meds • Improve communication through use of multidisciplinary teams

11. Proposed System Perfect chemotherapy delivery • Chemotherapy Intelligent Delivery System (ChIDS) • Blame-free reporting Essential System Characteristics • Uses available technologies • Real-time data • Feedback providing (closing the loop) • Designed to succeed (safe)

12. Intelligent Delivery System

13. Reporting Improvement Baseline Implementation 8 7 6 5 Near misses reported 4 3 2 1 0 -23 -21 -19 -17 -15 -13 -11 -9 -7 -5 -3 -1 1 3 5 7 9 11 13 15 17 Month relative to blame-free reporting implementation

14. Pediatric Oncology Pilot Registry

15. Clinical Improvement • Performance measures - rates of occurrences and time between occurrences (rare events) • Data plotted over time using statistical process control (SPC) charts • Quality improvement (QI) techniques used to drill down to root causes of variability in chemo delivery • Understanding of process variation used to improve delivery system through rapid tests of change • Improve outcomes