Lec 20: Chemo Safety Flashcards
What is ISMP?
What does the mandate of the Institute for Safe Medication Practices Canada (ISMP Canada) include?
- Independent, national not-for-profit agency committed to the advancement of
medication safety in all health care settings. - Mandate includes analyzing medication incidents, making recommendations for the
prevention of harmful medication incidents, and facilitating quality improvement
initiatives.
Definition: What is the Canadian Medication Incident Reporting and Prevention System (CMIRPS), and what is its purpose?
It’s a collaborative system that involves healthcare organizations, regulatory authorities, and other stakeholders in Canada.
> primary objective is to prevent harmful medication incidents by analyzing medication incidents, identifying UNDERLYING causes, and making recommendations for their prevention.
> The system facilitates the VOLUNTARY of medication incidents by healthcare professionals, patients, or consumers, and it provides a platform for sharing information and best practices related to medication safety.
> CMIRPS is MANAGED BY the Institute for Safe Medication Practices Canada (ISMP Canada), which is an independent, national not-for-profit agency committed to the advancement of medication safety in all healthcare settings.
Definition: What is the voluntary reporting of medication incidents, and who can report them?
The act of healthcare professionals, patients, or consumers reporting medication incidents that may cause or lead to inappropriate medication use or patient harm while the medication is in their control.
Definition: What is a medication incident, and what is its simplified definition?
- Medication Incident: Any preventable event that may cause or lead to inappropriate medication
use or patient harm while the medication is in the control of the healthcare
professional, patient, or consumer.
–> Simplified: is basically any mistake involving MEDICATION, or a problem that COULD CAUSE A MISTAKE WITH MEDICATION.
Which Chemo-related incident was the most commonly reported/highest?
Administration of Medication (34%) , * Dispensing (27%), then prescribing and monitoring (both 11%).
What is the def of CRITICAL INCIDENT?
An incident resulting in serious harm (loss of life, limb, or vital organ), or somethin happened that could have caused that, and NEEDS IMMEIDATE INVESTIGATION AND RESPONSE.
What is a root cause analysis?
it’s a problem-solving method used to identify the underlying cause(s) of an issue or event in order to prevent its recurrence.
What do Root Cause analyses focus on? (3)
1)
2) understanding what?
3) does it assign blame?
1) SYSTEMS and processes/procedures.
2) Understanding that individuals involved did not intentionally act to cause
harm
3) Does NOT assign blame
What are the 6 changes implemented as a result of the RCA from CASE #1 (where nurse programmed pump improperly cuz of miscalculation and infused 5-fu over 4 hrs instead of 4 days)?
1) ___________ mandatory.
2) Incorporate ______ and _________into medication order forms/worksheets (i.e. pilots taking off).
3) Have A ___________FOR DOCUMENTING _________this training must be incorporated into staff orientation and recirtifications).
4) must use__________ to check calculations (i.e. does this LOGICALLY make sense, rather than just focusing on the number).
5) must MINIMIZE _________ in workplace to prevent inattentiaonla blindness (i.e. no radio/music).
6) Implementation of PROCESS CHANGES including easy to calculate worksheets, and the use of _____ PUMPS to deliver infusions in order to reduce _______.
Changes IMplemented from RCA of CAse #1 (where nurse programmed pump improperly cuz of miscalculation and infused 5-fu over 4 hrs instead of 4 days):
1) Independent Double Checks mandatory: where two clinicians separately check alone and apart from
each other, then compare results to prevent confirmation bias.
2) Incorporate CHECKLISTS and CALCULATIONS into medication order forms/worksheets (i.e. pilots taking off).
3) Have A STRUCTURED PROCESS FOR DOCUMENTING DOUBLE CHECKS (this training must be incorporated into staff orientation and recirtifications).
4) must use MENTAL ESTIMATIONS/COMMON SENSE to check calculations (i.e. does this LOGICALLY make sense, rather than just focusing on the number).
5) must MINIMIZE DISTRACTIONS in workplace to prevent inattentiaonla blindness (i.e. no radio/music).
6) Implementation of PROCESS CHANGES including easy to calculate worksheets, and the use of ELASTOMERIC PUMPS to deliver infusions in order to reduce INFUSIONAL VARIANCE.
What is the ROUTE that VINCRISTINE CAN ONLY be given through?
IV ONLY!!!! **
Why?
causes degenreation of neurons, but bcuz it can’t penetrate BBB, we don’t worry about central toxicity unless given INTRATHECALLY (FATAL). Dose limiting peripheral and autonomic neuropathy an issue, but not cns toxicity.
Vincritistine is commonly mixed up with what other chemotoxic agent?
CYTARABINE.–> COMMON error cuz vincristine IV and Cytarabine IT are both clear and administered on same time of day. As a result, it’s a common error to inject VINCRISTINE INTRATHECALLY cuz Cytarabine is admin IT (intrathecally), and ppl get mixed up.
What are the first signs of VINCRISTINE INTRATHECAL ADMIN?
- First signs are leg weakness, leg pain and loss of the tendocalcaneus
reflex - Autonomic dysfunction with urinary retention
- Symptoms of meningitis (neck stiffness and high fever)
- CNS failure (respiratory failure and death)
Why is PREVENTION so important with accdiental admin of Vincristine IT?
Cuz trx is mostly ineffectual.
All ERRORS of Vincristine being administered intrathecally have
occurred when what was done?
- What was changed in order to prevent this error?
All ERRORS of Vincristine being administered intrathecally have
occurred when Vincristine was prepared in a syringe.
- As a result, VINCRISTINE CANNOT BE LEFT IN A SYRINGE, can only be kept in a MINIBAG (if it’s not a syringe, no way to phsycially put it into spine. If make sure it’s always in mini bag, there’s no chance it could happen. So just never put vincristine in a syringe so no one picks it up and thinks its cytarabine.)
What are strategies to avoid vincristine errors?
1) Dilute Vincristine in a vol ideal for IV infusion (50mL NS) and ONLY PACKAGE IN A MINIBAG (that way, cannot mistake it for IT injection).
2) Do “Time Outs”, where at least 2 HCPS read out loud the label and veryify/document the correct patient, drug, dose and route.
3) have a DESIGNATED SPACE where INTRATHECALS ONLY are kept, PACKAGE it PRODUCTS IN ANOTHER BAG LABELLED CLEARLY WITH “FOR INTRATHECAL USE ONLY” and package can only be remvoed by person administereing the drug, and more CLEAR labelling.
