The Pharmaceutical Journal
Vol 273 No 7323 p658-659
30 October 2004

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British Oncology Pharmacy Association

Focus on errors in systems, not people, to improve chemotherapy safety

Adverse drug events can be massively reduced by focusing on the systems that lead to errors, rather than the people who make them, Winson Soo-Hoo said. He and his team at the Children’s Hospital of Philadelphia achieved an 84 per cent decrease in chemotherapy medication errors by implementing such a “systems” approach to chemotherapy safety.

Mr Soo-Hoo argued that it is a mistake to focus on people as the cause of errors and to expect regulation, litigation and punishment to reduce errors.

A “systems” approach that recognises that people do make mistakes, and reflects that fact in the development of systems which make errors less likely to occur, is much more effective at preventing medication errors.

In examining its chemotherapy delivery system, the Children’s Hospital of Philadelphia drew up a 20-page flow sheet of the chemotherapy ordering and delivery process, which, Mr Soo-Hoo explained, was shown to everyone involved in medication errors: “All individuals who made errors were asked to look at the flow chart and, focusing on the system rather than the individual, we performed root cause analysis to identify weak spots in the system.”

The Children’s Hospital of Philadelphia then implemented a “rapid action change” process, in which minimal data were collected, small changes to the process were made, the changes were piloted, results analysed and, if appropriate, the change was implemented across the hospital.

Since many of the errors occurred in administration, a principal goal of the system was to make it so that orders were clear to the nurse. “Even though our project improved the medication system for the whole process, it had its greatest impact at the nursing end, because they were the ones with a lot of the actual errors,” Mr Soo-Hoo explained.

Mr Soo-Hoo and his team also found that non-standard orders led to many of the medication errors: 13 per cent of all chemotherapy orders were non-standard orders, but they accounted for 33 per cent of errors. So they increased the use of standard orders from 60 per cent to 90 per cent and reduced the number of errors as a result.

Give patients internet information

Although the internet is the second most widely used source of information for newly referred cancer patients and 65 per cent of them would like their doctor to choose information for them, only 1 per cent of patients have internet information provided to them by doctors. So said Nicholas James, of the Institute of Cancer Studies at the University of Birmingham, describing the findings of a survey of cancer patients and their carers.

In fact, information from the internet was most often provided by family or friends: “This is the second most prevalent form of information used by patients and it’s coming from someone who knows nothing about their cancer. They might not even know which cancer they have.”

Face-to-face interviews with 800 newly referred patients and 200 carers were conducted for the ACCIS (acceptability and usefulness of the internet as a source of information for cancer patients) study. Professor James said that the findings question how pharmacists and other health professionals give information to patients.

He called on health professionals to reject their negative view of patients bringing internet printouts to consultations: “There’s a feeling that it’s something that is actually a bit of a pain, patients coming in with reams of internet printouts and doctors having to sort out the consequences of it. Actually I’d like to turn that perception around and say you need to be pre-empting that by giving patients material from the internet that is relevant to them, rather than the other way round.”

“One of the biggest problems patients have is figuring out what is the relevant stuff and what is the irrelevant stuff,” Professor James said. It is here that health professionals can be an enormous help and this can be done easily, he said: “There are some simple strategies, for example, directed web use, which we found worked extraordinarily well and had a big educational impact. One of the things I do now with patients that I see is I write out a list of topics as we discuss them. I give them this ‘information prescription’ to take to our patient information room and then for each of those topics they get a printout. So they get veryfocused information and it feels like a personalised service to them.”

Transparency is key to champion choice

“We want people with cancer to be able to exercise choice in treatment and care,” said Joanne Rule, chief executive of CancerBACUP, adding that transparency is essential to this patient-centred agenda. “I firmly believe that you can’t have choice without transparency and that transparency will create a strong driver towards equity.”

Transparency will also, she argued, help to ease tensions between the level of choice patients have been led to expect and what they will receive. It will not, for instance, be possible for all cancer patients to be offered a choice of four or five treatment locations, particularly if the capacity does not exist in their area.

One of the challenges the choice agenda poses for all health professionals is, Ms Rule argued, providing patients with a meaningful understanding of the risks and benefits of different treatments: “Most health professionals are much better at communicating risk than they are at providing any really good communication of benefit in which to frame it.”

She added that oncology pharmacists will champion patient choice by extending their roles.

Look ahead to ensure equity of access to new treatments

Horizon scanning helps to ensure equity of access to appropriate treatments, Joanne Andrew, oncology horizon scanning pharmacist at Glasgow Royal Infirmary, argued.

The likely impact of drugs coming to market in the next year or two, in terms of number of patients treated for a given cost, can be determined, she said, from the size and nature of the patient population, the results of any clinical trials, the time to launch, and clinical need. Aspects such as patient eligibility testing are likely to become more important in the future, given the number of new drugs targeted to specific tumour characteristics.

Mrs Andrew highlighted a wide range of exciting new treatments for which an assessment of likely impact would be important, including: encapsulated paclitaxel (Taxol) for the treatment of breast cancer; bevacizumab (Avastin), an anti-angiogenesis drug for colorectal cancer; cisplatin, vinorelbine (Navelbine), pemetrexed (Alimta), gefitinib (Iressa) and erlotinib (Tarceva) for lung cancer; and cetuximab (Erbitux), gefitinib, and tirapazamine for head and neck cancer.

In addition to scanning for new drugs, Mrs Andrew argued that it is also important to review new and extended uses for existing medicines. For instance, the roles of aromatase inhibitors, including letrozole (Femara), anastrozole (Arimidex) and exemestane (Aromasin) in the adjuvant and neoadjuvant treatment of breast cancer are expanding, and possible new indications for docetaxel (Taxotere) in prostate and breast cancer are likely to have a significant impact in 2005. Extended indications for colorectal cancer for oxaliplatin and capecitabine, and new indications for rituximab (MabThera) in the treatment of lymphoma are also expected to have a significant impact on clinical practice next year.

Fitting new drugs into multiple myeloma treatment regimens

The field of multiple myeloma treatment has been through interesting times, but the challenge over the next few years will be to define precisely where new drugs, such as thalidomide, bortezomib, Revimid, Actimid and arsenic trioxide, fit into the treatment algorithm for patients with myeloma, Prem Mahendra, consultant haemato-oncologist, University Hospital Birmingham, said.

Future treatments may, she said, involve incorporating bortezomib (Velcade) up front: “VAD [vincristine, adriamycin and dexamethasone] has been around for about 25 years and there has been nothing found that is better than VAD, but whether Velcade and chemotherapy might be more effective than VAD remains to be seen.”

The immunomodulatory agents Revimid (CC-5013) and Actimid (CC-4047) may also prove useful in future. These have been termed the “sons of thalidomide”, because they appear to retain the immunomodulatory effects of thalidomide, but do not cause phocomelia. It may also be possible to use Revimid and Actimid in patients to whom it would be difficult to give thalidomide and Revimid may be useful during maintenance or after an autograft.

Dr Mahendra added that use of bone-targeting methods is another possible avenue for treatment of multiple myeloma. This could work by inhibiting part of the tumour-necrosing factor ligand responsible for osteoclast activity. Disrupting these feedback loops may be an important treatment for bone disease and may also help with treatment of the disease as a whole.

Other agents that may be used in the future and which are currently involved in trials include arsenic trioxide and neovastat, a compound found in shark cartilage, which has multiple anti-angiogenic properties.