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

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

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!

Patient Safety at VUMC

• •

Blood Transfusion Safety

• MRI Safety – Westchester Medical Center, Valhalla, NY

Chemotherapy Delivery

– Dana Farber Cancer Institute, Boston

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

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.

Metrics - Across Chemo Delivery

Prescriptions - Physician Processing - Pharmacy Administration - Nursing

Metrics - Chemo Delivery Processes

Prescribing Processing Administration Correct Drug Correct Dose Correct Route Correct Schedule Omission Allergy Contra Indications Monitoring Patient in need

Errors and “Near Misses”

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

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)

Intelligent Delivery System

Decision Support System

(Inbedded safety logic)

Blame-Free ADE Reporting

(Process focused)

Perfect Chemotherapy Delivery Clinical Improvement

(generate hypotheses, tests of change)

Chemotherapy Registry

(tracks metrics over time)

Reporting Improvement

Baseline Implementation

8 7 6 3 2 5 4 1 0 -23 -21 -19 -17 -15 -13 -11 -9 -7 -5 -3 -1 1 3 5 7 9 11 13 Month relative to blame-free reporting implementation 15 17

Pediatric Oncology Pilot Registry

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