Anthony C. Easty

Safe handling of cytotoxics: guideline recommendations.

BACKGROUND This evidence-based practice guideline was developed to update and address new issues in the handling of cytotoxics, including the use of oral cytotoxics; the selection and use of personal protective equipment; and treatment in diverse settings, including the home setting. METHODS The guideline was developed primarily from an adaptation and endorsement of an existing guideline and from three systematic reviews. Before publication, the guideline underwent a series of peer and external reviews to gather feedback. All comments were addressed, and the guideline was amended when required. The guideline applies to health care workers who could come into contact with cytotoxic drugs at any point in the medication circuit. The intended users are hospital administrators, educators, and managers; occupational health and safety services; and pharmacy and health care workers. RESULTS The recommendations represent a reasonable and practical set of procedures that the intended users of this guideline should implement to minimize opportunities for accidental exposure. They are not limited to just the point of care; they cover the entire chain of cytotoxics handling from the time such agents enter the institution until they leave in the patient or as waste. CONCLUSIONS Reducing the likelihood of accidental exposure to cytotoxic agents within the medication circuit is the main objective of this evidenced-based guideline. The recommendations differ slightly from earlier guidelines because of the availability of new evidence.

ORDER SETS IN HEALTH CARE: A SYSTEMATIC REVIEW OF THEIR EFFECTS

OBJECTIVES Order sets are widely used in hospitals to enter diagnosis and treatment orders. To determine the effectiveness of order sets in improving guideline adherence, treatment outcomes, processes of care, efficiency, and cost, we conducted a systematic review of the literature. METHODS A comprehensive literature search was performed in various databases for studies published between January 1, 1990, and April 18, 2009. A total of eighteen studies met inclusion criteria. No randomized controlled trials were found. RESULTS Outcomes of the included studies were summarized qualitatively due to variations in study population, intervention type, and outcome measures. There were no important inconsistencies between the results reported by studies involving different types of order sets. While the studies generally suggested positive outcomes, they were typically of low quality, with simple before-after designs and other methodological limitations. CONCLUSIONS The benefits of order sets remain eminently plausible, but given the paucity of high quality evidence, further investigations to formally evaluate the effectiveness of order sets would be highly valuable.

Toward successful migration to computerized physician order entry for chemotherapy

BACKGROUND Computerized physician order entry (cpoe) systems allow for medical order management in a clinical setting. Use of a cpoe has been shown to significantly improve chemotherapy safety by reducing the number of prescribing errors. Usability of these systems has been identified as a critical factor in their successful adoption. However, there is a paucity of literature investigating the usability of cpoe for chemotherapy and describing the experiences of cancer care providers in implementing and using a cpoe system. METHODS A mixed-methods study, including a national survey and a workshop, was conducted to determine the current status of cpoe adoption in Canadian oncology institutions, to identify and prioritize knowledge gaps in cpoe usability and adoption, and to establish a research agenda to bridge those gaps. Survey respondents were representatives of cancer care providers from each Canadian province. The workshop participants were oncology clinicians, human factors engineers, patient safety researchers, policymakers, and hospital administrators from across Canada, with participation from the United States. RESULTS A variety of issues related to implementing and using a cpoe for chemotherapy were identified. The major issues concerned the need for better understanding of current practices of chemotherapy ordering, preparation, and administration; a lack of system selection and procurement guidance; a lack of implementation and maintenance guidance; poor cpoe usability and workflow support; and other cpoe system design issues. An additional three research themes for addressing the existing challenges and advancing successful adoption of cpoe for chemotherapy were identified: The need to investigate variances in workflows and practices in chemotherapy ordering and administrationThe need to develop best-practice cpoe procurement and implementation guidance specifically for chemotherapyThe need to measure the effects of cpoe implementation in medical oncology. CONCLUSIONS Addressing the existing challenges in cpoe usability and adoption for chemotherapy, and accelerating successful migration to cpoe by cancer care providers requires future research focusing on workflow variations, chemotherapy-specific cpoe procurement needs, and implementation guidance needs.

Towards improving inter-team coordination in the surgical process: a breakdown detection method

Coordination breakdowns in clinical work are a common concern for patient safety. To design technology that facilitates coordination and prevents breakdowns, we need to be able to reliably detect them and analyze their impact in daily work. A breakdown detection method is proposed as a useful approach to the management of breakdowns in inter-team coordination within the context of the daily operations of surgical units. By mapping information flow expectations for various information needs in clinical work -- such as patient status information flow, schedule status information flow, staffing coordination information flow, etc. -- an analyst can derive a set of predictions that serves as input to the algorithm for detecting the breakdowns. The method was verified over data from three sets of observational studies in two different hospitals. Performance analysis demonstrates excellent detection rate. The method can be utilized to assess the amount of breakdowns for different types of breakdowns, before and after technology implementation.

Approaching the hotspot increases the impact: Process breakdowns in a safety-critical system-of-systems

This paper reports a study that examines process breakdowns in the operations of a hospitals surgical unit. We find a correlation between the stage in the surgical process in which a breakdown is detected and the breakdown impact. We derive a model of the relationship between breakdown detection, impact, and safety within the surgical domain. We discuss the practical implications for targeted breakdown prevention and detection within the process, and the latent effects on safety.

Validating the integrity of one-way check valves for the delivery of contrast solution to multiple patients

The infusion of contrast solution into multiple patients from a single package is desired in clinics concerned about the high cost of the solution. The use of check valves in the infusion line is a method of protection used to reduce the risk of blood-borne cross-contamination. Through testing of the operating characteristics of the valves and infusion system and the high back pressure testing of the valves, the suitability of this method is assessed. The results indicate that the use check valves reduce the risk of now from the patient to the injector. Results also indicate that the use of sprung valves, those which require a significant forward pressure to open them are more appropriate for this application.