JANUARY 2001
The University of
Kansas Hospital
Purpose: To assure completeness, accuracy, and
appropriateness of all chemotherapy
orders written within the University of Kansas Hospital.
1.0 Chemotherapy Prescribing Authority
1.1 Chemotherapy orders, and any modifications to such orders,
shall be prescribed only by the persons and only in the manner permitted for
the issuance of treatment orders by the Rules and Regulations of the Medical
Staff (“Authorized Prescribers”)
1.2 Members of the House Staff may write
chemotherapy orders subject to the following restrictions:
1.2.1 An order for a patient’s first cycle of chemotherapy must be
reviewed and countersigned by the member of the Medical Staff who is
responsible for the patient’s chemotherapy before administration of such first
cycle is initiated.
1.2.2 Orders for subsequent cycles of chemotherapy containing no
modifications from the first cycle shall be countersigned by a member of the
Medical Staff within 24 hours.
1.2.3 Fellows, who are members of the House Staff and under the
direct supervision of the Authorized Prescriber, may also write chemotherapy
orders and are exempt from restrictions 1.2.1 and 1.2.2.
1.3 Verbal orders relating to a patient’s chemotherapy are
acceptable only when all of the following conditions are met:
1.3.1 The patient requires immediate treatment and the authorized
prescriber is not immediately available.
1.3.2 The verbal order is issued by the Authorized Prescriber or
Fellow as designated in section 1.2.3.
1.3.2 The verbal order is
a modification of an existing
chemotherapy order signed in accordance with Sections 1.2.1, 1.2.2 or
1.2.3.
1.3.3 The modification, if outside of specified guidelines, must
be signed by the Authorized Prescriber as defined by Rules and Regulations
Medical Staff.
1.3.4 The verbal order is given directly to a Registered Nurse,
certified Physician Assistant or licensed Pharmacist. The order must be
repeated to the authorized prescriber and then immediately written in the
patient’s chart.
1.4 Orders for investigational chemotherapeutic agents may be
prescribed only by Authorized Prescribers who are listed as principal
investigators or co-investigators on a research study approved by the Human
Subjects Committee. Fellows, who are
members of the House Staff and under the direct supervision of the Authorized
Prescriber listed as the principal investigator or co-investigator on the
Approved Research Study, may also write such orders.
2.0 Standards
for Chemotherapy Order Format
2.1 Chemotherapy order forms shall be utilized for all
antineoplastic agents, excluding:
Oral
chemotherapeutic agents
Topical
chemotherapeutic agents
Chemotherapeutic
agents used in the Operating Room
2.2 Other Chemotherapy Order Forms may be
used, subject to the approval of the Medical Records Committee, the Medical
Executive Committee and the Authority, and may be utilized for :
- commonly used chemotherapy regimens.
- investigational chemotherapy protocols.
2.3 A
complete chemotherapy order will
consist of:
2.3.1 Patient name
and hospital ID number
2.3.2 Diagnosis
2.3.3 Patient height
and weight when needed for dosing of agents
2.3.4 Designation of
KUMC protocol # or investigational study name #
2.3.5 Start date
2.3.6 Laboratory
criteria necessary for treatment decision-making (e.g. AGC>1000)
2.3.7 Drug name
(generic name preferred). All unclear
names are to be clarified prior to order entry and/or administration to the
patient.
2.3.8 Proper
sequence of administration
2.3.9 Dose per m2
or dose per kg written or verified by the physician.
2.3.10 Calculated
dose clearly written by the physician or pharmacist.
2.3.11 Rate ( e.g. Bolus, 24 hour continuous
infusion, 2 hour infusion).
2.3.12 Interval ( q
12hr, q 24hr, q week)
2.3.13 Route (e.g. IV,
PO, IM, SQ, intrathecal, intraperitoneal, limb perfusion, hepatic embolism).
2.3.14 Duration or
total number of doses (e.g. x 4 doses, x 1 dose)
2.3.15 Ancillary IV=s
or medications necessary for treatment (e.g., mannitol 12.5g IVP, hydration
fluids).
2.3.16 Antiemetics or
an indication for pharmacist to prescribe per guidelines.
2.3.17 Physician signature and date.
2.3.18 Consent form,
signed by the patient prior to the first dose of investigational
chemotherapeutic protocols.
|
Guideline
for Writing Dose
|
Correct
Method
|
Incorrect
Method
|
|
Do not write total dose for the whole
course.
|
1. 500 mg daily as a continuous
infusion x 4 days.
2. 500 mg over 1 hour daily for 4
days.
|
1. 2000 mg CIVI over 4 days
2. 2000 mg over 4 days for 1 hr daily.
|
|
Use metric units
|
1 gram , 500 milligrams
|
1 teaspoon, 1 ounce
|
|
Always use leading zeros
|
0.8
|
.8
|
|
Never use trailing zeros
|
8
|
8.0
|
|
If the patient is >20% above ideal weight the prescriber should specify if the
calculated dose is based on ideal, actual, or adjusted weight.
|
Specify actual, ideal, or adjusted
weight.
|
No specification made.
|
3.0 Chemotherapy Order Processing and Timeliness
The University of Kansas Hospital recognizes the value of
interdisciplinary review of the chemotherapy and the importance of patient
satisfaction in the timing of therapy.
As such, all Authorized Prescribers who issue orders for chemotherapy
shall adhere to the following:
3.1 To facilitate safety and timeliness, it is
preferable that chemotherapy orders for scheduled admissions to be administered
within the facility be submitted to the pharmacy department at least 12 hours
before the patient is scheduled to receive therapy. Exceptions to the 12 hour requirement, to enhance patient
satisfaction while maintaining safety, will be made as staffing, space and
workload allow.
3.2 The Authorized Prescriber who issued the
chemotherapy order, or a fellow who is a member of the House Staff under the
supervision of the Authorized Prescriber, shall be available to the nurse and
pharmacist for clarification and adjustments of the chemotherapy order as
necessary.
4.0 Protocol Verification
4.1 The
Department of Pharmacy will maintain a listing of a) all protocols and associated guidelines
currently approved for use in the Hospital; and b) an updated list of Hospital-approved exceptions to
said protocols.
4.2 All
chemotherapy orders shall adhere to Section 4.1 or those orders that can
be independently
confirmed via a formal reference (i.e., textbook, abstract, protocol, handbook). In the case of the latter, the chemotherapy
order shall cite the reference upon
which the order is based, and a copy of the reference shall be attached to the
Chemotherapy Order Form.
4.3 A chemotherapy
order which does not comply with Section 4.2 will not be dispensed, and the
pharmacist who received the order shall notify the Authorized Prescriber of such immediately.
4.3.1 If the
Authorized Prescriber who issued the noncompliant order writes the missing citation on, and attaches
a copy of the reference to, the Chemotherapy Order Form, the order shall
be deemed compliant, and the
pharmacist shall dispense accordingly.
4.3.2
If the Authorized
Prescriber chooses to modify the regimen so that it adheres to a documented
protocol which meets the requirements of Section 4.2, a new order will be
required, and the pharmacist will dispense accordingly.
4.3.3
In the event that the
Authorized Prescriber who issued the order is unable to provide the
documentation required by Section 4.2 and desires that the order remain as
written, the pharmacist, or his/her designee, shall refer the order to the
Chair of the Pharmacy and Therapeutics’ Chemotherapy Subcommittee or to the
Chair’s designee.
4.4 The Chair of
the Pharmacy and Therapeutics’ Chemotherapy Subcommittee, or his/her designee, upon receipt of a
referral from the pharmacist pursuant to Section 4.3.3 shall review the order and, as necessary in
his/her discretion, discuss the order
and any other relevant matters with the pharmacist who referred the order and the Authorized Prescriber who
issued the order.
4.4.1
If the Chair, or
his/her designee, determines that the order is correct as written and meets the
requirements of Section 4.2, he/she shall indicate that the dose may be
dispensed as written. The Chair,
his/her designee, or the Pharmacist is required to make such notation in the
chart.
4.4.2
If the Chair, or
his/her designee, cannot determine that the order is correct as written and
meets the requirements of Section 4.2, he/she may recommend either that the
order be rewritten so that it comply with Section 4.2 or that the Authorized
Prescriber seek a Compassionate IND.
4.4.3
If the Chair, or
his/her designee, determines that the order contains a protocol which is
investigational, he/she shall refer the order to the Human Subjects Committee
of the Hospital for approval.
4.4.4
The Chair, or his/her
designee, shall communicate any recommendation to both the Authorized
Prescriber who issued the order and the pharmacist for subsequent action.
4.4.5
The pharmacist shall
document the initiation and outcome of the dose verification process outlined
in this Section 4.4 on the Chemotherapy Order Form and forward the Chemotherapy
Order Form to the Pharmacy and Therapeutics Committee for review.
4.5 Any nurse who questions whether a chemotherapy order complies
with Section 4.2 shall follow dose
verification guidelines as outlined in the Department of Nursing Governance Standards,
Tech-03, Administering Intravenous Chemotherapeutic Agents.
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