Selection of Opportunities for Improvement (Outline of Problem)
Chemotherapy ordering is a complex process, it involves the need for precision with regard to the drug, dose, diluent, infusion sequence, duration and the need to modify doses based on current laboratory values or toxicity assessment. Prescribing errors involving chemotherapy could result in potentially harmful effects and/or diminished anticancer response in cancer patients and further worsen their quality of life. The inappropriate ordering was reported as 46.6% based on the Surgical Department chemotherapy order forms received by Oncology Pharmacy Unit.
Key Measures of Improvement
The key indicator for improvement was measured by the percentage of inappropriate ordering of chemotherapy by Surgical Department. The standard is 10% as agreed in Pharmacy Department Meeting.
Process of Gathering Information
A cross-sectional study was conducted using universal sampling for all chemotherapy orders received during verification study (n=281, March – April 2018) and post-intervention study (n=258, October – November 2018) by using designated data collection form. At the same period, cross-sectional questionnaire survey (n=40) was carried out through convenience sampling among prescribers, pharmacists and nurses to determine contributing factors.
Analysis and Interpretation
The verification study has shown that the inappropriate ordering of chemotherapy was 51.2%. Based on Pareto analysis, the main contributing factors were identified to be complexity of chemotherapy regimens, no proper documentation on past chemotherapy cycle ordering information and multiple chemotherapy order forms to be filled up.
Strategy for Change
Remedial measures included introduction of new chemotherapy order form with prefilled chemotherapy regimen information, multiple chemotherapy cycles ordering information in one form, and available in pre-printed copies. All previous multiple forms (Chemotherapy Ordering Form, Manual Prescription and List A Drug Ordering Form) were replaced by one new chemotherapy order from. Besides, briefing during House Officer orientation and the revision on Standard Operating Procedure were conducted.
Effects of Change
Remedial measures reduced the inappropriate ordering of chemotherapy from 51.2% to 7.8% in October - November 2018 and to 6.9% subsequently in January - February 2019. Achievable benefit not achieved (ABNA) was reduced from 41.2% to -2.2% and subsequently -3.1%.
The new chemotherapy order form was expanded to other wards in HRPB. Sharing experience session was carried out at Perak state level meeting, Hospital Slim River has started to adopt it. We will continue the routine education and to share the remedial measures to other hospitals in Perak state.
Value Added Features
A cross-sectional questionnaire survey has shown good feedbacks from the staffs on reducing ordering time, ordering cost, processing time and workload. Overall satisfaction was reported as 87.5%.