Safe Use of Chemotherapy; Safe Administration and Patient Safety Flashcards
What does the NHS Quality Triangle entail, and how does it relate to managing healthcare risk? Why does it exist?
- Safety
- Effectiveness
- Experience
> Keep me safe
Make me better
Treat me with respect
» Patients and public expect total certainty and safety.
Is legislation or regulation better for managing risk?
- Mixture of both
- Move away from legislation to regulatory expectations and ‘fitness to practice’
How can risk be managed, prevented?
- Expect unexpected, assume the worst.
- Categorise seriousness, impact and consequences of harm if it were to occur.
What chemotherapy hazards are there WRT exposure?
Exposure:
- Absorption (spillage, splashing, needle-stick injuries)
- Inhalation (over-pressurising vials during preparation)
- Ingestion (eating, drinking, smoking in contaminated areas/poor hygiene)
What is the risk of exposure to chemotherapy?
- Cytotoxics interfere w/cell division; normal cells damaged too.
- Acute (serious irritation of skin, eyes, mucous membranes e.g. methotrexate) and chronic health effects (mutagenic/teratogenic)
- Acute vs prolonged occupational exposure (not as much of a risk due to PPE etc.)
What legislation and guidance govern chemotherapy exposure risk?
- Health and Safety at Work Act 1974
- Management of Health and Safety at Work Regulations 1999
- COSHH 2002
- Employers’ responsibility under H&S legislation/COSHH
What does Health Surveillance entail for chemotherapy risk?
- System of ongoing health check for people exposed to risk from cytotoxic drugs etc.
- Can measure concentration on skin, body fluids etc.
- HSE recommend accident records to keep a health record
What is extravasation in terms of cytotoxic chemotherapy? When could it occur?
- Leakage of IV drugs from vein into surrounding tissue
- When IV medication passes into tissue around a blood vessel, resulting in minor discomfort to severe damage
What do the types of injury extravasation can cause depend on?
- Drug
- Volume
- Site
- Duration of exposure
- Reaction
How are chemotherapy drugs classified WRT their extravasation risk?
- Non-vesicant; no damage, mild pain e.g. cyclophosphamide, 5FU (sx SC fluid etc)
- Irritant; pain and phlebitis (inflammation at site or along vein) e.g. cisplatin, etoposide, methotrexate
- Vesicant; blistering, ulceration and necrosis (destroying muscle, nerves, tendons etc.) e.g. carmustine, anthracycline antibiotics, paclitaxel and vinca alkaloids.
What are the risk factors for extravasation?
- Frailty
- Age (elderly/children)
- Confused and sedates patients
- Peripheral neuropathy (reduced sensation)
- Repeated IV infusion/injections
What are the steps taken to prevent extravasation?
- Staff proficiently trained
- Avoid cannulae in the dorsum of the hand, foot, ankle, near joints/joint spaces (limited soft tissue protection), ante cubital fossa etc, use muscley/fatty sites.
- Use smallest 22/24 gauge polyurethane cannula and warm water soak/hot pack to promote vasodilation
- Cannulated area covered with transparent dressing, no bandaging to allow observation.
- Nurse sits at patient level facing patient, administers slowly, asking patient to report pain/burning at site during or after.
What is the treatment for severe extravasation?
Severe extravasation; surgical debridement (removal of dead/damaged tissue), reconstruction w/skin grafts.
Outline the principles of the BOPA 4 phase approach to treating extravasation.
- Phase 1 (cool and calm); apply cold pack to reduce dispersion and cellular uptake etc
- Phase 2 (localise and neutralise); intermittent cold treatment, syringe to remove it
- Phase 3 (dilute and disperse); S/C hyaluronidase 1500 U
- Phase 4 (report and learn); document w/photos, incident reporting.
How can the symptoms of extravasation be treated?
- Topical/oral/parenteral antihistamine
- NSAID, paracetamol or opioid
What is the Swiss cheese model to preventing errors?
- Systems approach, anticipating risk developing
- Build successive layers of defences; some ‘engineered’, others rely on people, others on procedural controls
- All defences have weaknesses (holes), which tend to change (open, close, shift); where failure in one layer does not result in catastrophe, only when all weaknesses align.
- Failures are active (unsafe acts, mistakes, violations) or latent (design failures, strategic decisions, conditions).
Why are Safety Alerts published, and what are the consequential actions required?
- Arise from wrong dosage, frequency, quantity or duration etc.
- Actions required: l
> local approved policies to describe safe use
> treatments to be initiated by cancer specialist
> prescribed in context of a written protocol or treatment plan (monitoring information, toxicity guidance)
> Written patient information incl. full treatment details
> Access to further information
> Who to contact if unwell
What is Never Event?
- Serious, largely preventable patient safety incident that should not occur if availible preventative measures have been implemented
- Errors leading to severe harm or death (mandatory to report)
What are the 9 medication-related ‘never events’?
- Wrongly prepared high risk injection
- Maladministration of K+ solution
- Wrong route oral/enteral treatment
- IV administration of epidural
- Maladministration of insulin
- Overdose of midazolam in sedation
- Opioid overdose in naive patient
- Wrong route chemotherapy
- Daily use of PO MTX
What recommendations were made from the Toft Report re. IV Vincristine (vinca alkaloid) being administered IV causing death?
- Closed loop communication (repeat message back to person)
- Avoid assumptions
- Separate Rx charts
- Different days of administration for IV and IT products
How should a HCP respond/react to an error?
- Apologise
- Attempt to remedy or support
- Explain what happened and any short/long-term consequences
- Duty to be open and honest with colleagues, employers, anyone else (inc. GPhC)
»> Professional duty of candour
What are the 6 stages of coping as defined by Quality and Safety in Healthcare 2009, and the 3 possible outcomes?
- Chaos and response
- Intrusive response
- Restoring personal integrity
- Enduring the inquisition
- Obtaining emotional first aid
- Moving on
> Drop out
Survive
Thrive
What is an effective coping strategy for making an errors?
- Ensure mistake is a valuable lesson learned
- Rather than a personal, professional or career-defining failure.
