Kathy Vu

Improving the Safety and Quality of Systemic Treatment Regimens in Computerized Prescriber Order Entry Systems

PURPOSE Systemic treatment (ST) computerized prescriber order entry (CPOE) and preprinted orders (PPO) are proven to reduce errors. There is no known guidance in oncology to facilitate high-quality, accurate regimen development and review; hence, this was identified as a system-wide gap. This provincial initiative aimed to improve the quality of oncology regimens through a comprehensive review of systemic treatment (ST) regimens and the development of standards. METHODS A system-wide analysis of all active regimens (both CPOE and PPO) to ensure they were built as intended was conducted in 2015. Thirty-five hospitals (on behalf of 75 treatment facilities) were asked to report any unintentional discrepancies and details of the maintenance review process. Discrepancies were compiled, categorized, and analyzed for potential to cause harm. In addition, a multidisciplinary expert working group was formed to create best practice recommendations. RESULTS The review yielded a 94% response rate and took a total of 18 months to complete (70% completed within 9 months). The average number of regimens reviewed was 336 (range, 15 to 700; n = 9). Unintentional discrepancies were reported by nine hospitals (27%). A total of 369 discrepancies were reported (average, 55 per hospital), and 28 were deemed to have a moderate potential for harm. Only two hospitals (6%) had an established maintenance process; now, all have standard processes for review. Consensus-based recommendations for ST-CPOE and PPO regimen development and maintenance were developed. CONCLUSION The review identified unintentional discrepancies and, because of the potential for patient harm, corrective action has been taken. Identified discrepancies have been amended, and standard regimen development and maintenance review processes are now implemented system-wide to improve the quality and safety of systemic treatment delivery.

Influencing antiemetic prescribing practices and funding changes through evidence-based guidelines.

31 Background: In 2013 Cancer Care Ontario released updated antiemetic recommendations supporting the use of aprepitant-based combinations as 1st line therapy for highly emetogenic and 2nd line therapy for moderately emetogenic chemotherapy and discouraging the prolonged use of 5-HT3 antagonists. In 2014 changes were made in the Ontario drug formulary to align public funding to those recommendations. The impact of the changes in guidance and public funding on prescribing practices are now being analyzed. METHODS Using the Ontario Drug Benefit (ODB) database, data was extracted to analyze the prescribing practices of aprepitant, granisetron and ondansetron for chemotherapy-induced emesis between the pre-funding period (November 2013 to September 2014) and post-funding period (October 2014 to July 2015). RESULTS Prior to funding changes, an average of 197 prescriptions/month of aprepitant were billed to the ODB program totaling

Bringing provincial improvements to oral chemotherapy prescribing through co-ordinated regional initiatives.

22,422. After funding, an average of 1,165 prescriptions/month of aprepitant were billed totaling

Improving the safe delivery of systemic treatment by assessing concordance with labeling guidelines.

132,145. This represented a 490% increase in utilization. The combined 5-HT3 receptor antagonists prescriptions/month billed during the respective time periods were 5,592 (

Developing a culture of safety in systemic cancer treatment at the system level.

405,604) and 5,536 (

Chemotherapy safe handling and safe labeling guideline concordance evaluation: A Canadian experience.

402,628). This represented a 1% decrease in utilization. CONCLUSIONS There was a significant increase in aprepitant utilization and total expenditure to the ODB program indicating strong uptake of the triple-drug recommendation for highly emetogenic regimens. However, there was minimal change in prescribing practices related to the 5-HT3 receptor antagonists, indicating a reluctance to decrease utilization. Further work is necessary to discourage the prolonged use of 5-HT3 receptor antagonists.

Developing a standard approach to immune checkpoint inhibitor toxicity management in Ontario.

107 Background: Oral chemotherapy delivery is complex, making safe medication practices a high priority. Cancer Care Ontario, the provincial government agency responsible for continually improving cancer services in Ontario, undertook a jurisdiction-wide quality improvement initiative to ensure that all oral chemotherapy drugs are prescribed using Computerized Prescriber Order Entry (CPOE) or standardized Pre-printed Orders (PPO). The initiative was further enabled by changes to the provincial funding approach that flows facility funding for oral chemotherapy delivery. METHODS All 35 facilities prescribing chemotherapy in Ontario across 14 regions implemented strategies to work towards the common aim of reducing handwritten/verbal oral chemotherapy prescribing to zero by June 30th, 2015. Baseline audits were completed between Sept-Nov 2014; repeat audits were performed between Mar-May 2015. Each facility reported the number of patients that received an oral chemotherapy prescription, and the method of prescribing. RESULTS At baseline, 30% of audited prescriptions across the province were handwritten or verbal, which decreased to 9% by June 2015. Improvements were seen in thirteen of the 14 regions. Thirteen out of 35 facilities met the aim of 0 handwritten/verbal orders, with an additional 16 facilities seeing an improvement. Alignment with funding mechanisms, an early physician engagement strategy, and education of key stakeholders on CPOE systems were identified as key enablers to implementation. CONCLUSIONS Though the goal of zero handwritten/verbal prescriptions was not met by all facilities, the initiative encouraged a change in implementing safe prescribing practices for oral chemotherapy. Further audits will assess that the gain was sustained and that the provincial goal is achieved. This initiative is part of a larger strategy to standardize care for systemic treatment patients and promote a culture of safety in hospitals. [Table: see text].

Establishing best practice recommendations for systemic treatment regimen development and maintenance.

257 Background: Improper labeling of medication may lead to errors. In 2009, Cancer Care Ontario published Key Components of Chemotherapy Labeling, with recommendations for the necessary components and formatting of intravenous chemotherapy labels. A jurisdiction-wide evaluation for concordance occurred in 2011. Results were shared, improvement efforts were supported through a provincial quality network, and a re-evaluation was conducted in the fall of 2013. METHODS Three defined chemotherapy labels were evaluated at baseline and after improvement strategies were implemented at each of Ontarios 77 hospitals providing systemic treatment. Labels were reviewed centrally and awarded points for concordance for each of 15 guideline-specified criteria. RESULTS The provincial average overall score for concordance increased from 59% to 80% (p<0.001). Improvement was seen for 12 of the 15 criteria evaluated and for 64 of the 77 facilities. The greatest increase in overall score by a facility was 53.4%. The greatest overall improvement in score for an individual component was 67% (TALLman lettering). The scores of 2 components were unchanged, as 100% concordance was achieved on both the baseline and re-evaluation. CONCLUSIONS Improvement in concordance to chemotherapy labeling guidelines was observed following the implementation of a measurement strategy and improvement plans. This approach is one component of a larger strategy to promote a culture of safety in chemotherapy delivery in Ontario. [Table: see text].

Survey of community pharmacists regarding their role and desire for managing chemotherapy related toxicities in cancer patients.

230 Background: Chemotherapy ordering, preparation and delivery involve multiple providers and complex systems where high impact errors may occur. Cancer Care Ontario, a provincial agency responsible for continually improving cancer services in Ontario, Canada employs a comprehensive systematic approach to build a culture of safety for systemic treatment. METHODS A comprehensive strategy is applied at 77 systemic treatment hospitals in the Province. A multi-pronged approach is used that includes: 1) system planning, organization and funding, 2) engagement of health care providers working at the regional and local levels, 3) guidelines implementation and, 4) quality measurement. RESULTS Institutions are organized into regional networks, according to four levels of service complexity based on quality standards, planning, funding, coordination and health human resources. A customized, system-wide incident reporting system is available. Quality improvement is undertaken in several ways. Regional clinical and administrative leaders foster engagement with local providers and work is facilitated by a provincial multidisciplinary community of practice, an annual Safety Symposium, and local improvement projects with funding support. In this way, collaborative sharing and learning occurs across the Province. Comprehensive evidence-based guidelines have been produced addressing safe labeling, administration, handling and the use of computerized prescriber order entry systems. Routine performance management together with guideline concordance measurement, public reporting, planning for improvement and re-evaluation strategies, has produced system improvements. CONCLUSIONS A comprehensive, evidence-based and systematically applied approach to providing systemic cancer treatment can produce a culture of safety that is coordinated and standardized across multiple providers and provider sites.

Understanding the financial impact of beyond use date in a publicly funded cancer system.

179 Background: The safe delivery of chemotherapy is of utmost importance to patients, health care providers and systems administrators. Cancer Care Ontario and the Program for Evidence-Based Care published two guidelines addressing issues of chemotherapy safety: Safe Handling of Parenteral Cytotoxics (Safe Handling) in 2007 and Key Components of Chemotherapy Labeling (Safe Labeling) in 2009. Concordance with the two documents was evaluated across systemic treatment hospitals in Ontario in order to direct quality improvement initiatives. METHODS Since 2009, concordance with Safe Handling has been assessed annually by self-reported questionnaire as part of the regular provincial performance review process. In 2011, concordance with Safe Labeling was assessed by submission and scoring of five standardized chemotherapy labels demonstrating core and additional criteria. Core criteria included patient and drug information, administration information, as well as adherence to other guidelines related to abbreviations and units of measurement. Individualized regional scorecards were compiled highlighting areas of discordance and then used to develop improvement plans. RESULTS As of October 2011, 98% of Ontario hospitals providing chemotherapy had updated policies and procedures in place for the safe handling of cytotoxics, significantly improved compared to a baseline of 77% in 2009. Baseline evaluation of Safe Labeling performed in 2011 showed a provincial average of 64% concordance for core criteria and 63% for additional criteria. Regionally, concordance scores ranged from 55% to 80% for core criteria and 38% to 75% for additional criteria. CONCLUSIONS Concordance with safety practice guidelines has the potential to improve significantly with continued measurement and performance management. A baseline assessment serves to identify areas for quality and process improvements. Continued evaluation of guideline concordance is necessary in order to achieve the desired target rate for the province.