Abstract
BackgroundThere are serious safety risks associated with chemotherapy, often associated with interdependencies in regimens administered over months or years. Various strategies are used to manage these risks. Computerized provider order entry (CPOE) systems are also implemented to improve medication safety. Little is known regarding the effect of CPOE on how clinicians manage chemotherapy interdependencies and their associated safety strategies.MethodsWe conducted a multi-method qualitative study in a paediatric hospital. We analysed 827 oncology incidents reported following CPOE implementation and carried out semi-structured interviews with doctors (n = 10), nurses (n = 6), a pharmacist, and oncology CPOE team members (n = 2). Results were interpreted according to safety models (ultra-safe, high-reliability organisations [HROs], or ultra-adaptive).ResultsIncident reports highlighted two interrelated types of interdependencies: those within organisation of clinical activities and those inherent in chemotherapy regimens. Clinicians reported strategies to address chemotherapy risks and interdependencies. These included rigid rules and ‘no go’ contexts for treatment to proceed, typical of the ultra-safe model; use of time (e.g. planning only so far ahead) and sensitivity to operations, typical of HROs. We identified three different time horizons in CPOE use in relation to patients’ treatments: life-long, the whole regimen, and the ‘here and now’. CPOE supported ultra-safe strategies through automation and access to rules/standardisation, but also created difficulties and contributed to incidents. It supported the ‘here and now’ better than a life-long or whole regimen view of a patient treatment. Sensitivity to operations was essential to anticipate and resolve uncertainties, hazards, CPOE limitations, and mismatches between CPOE processes and workflow in practice.ConclusionsWithin oncology, CPOE appears to move the ‘mix’ of risk strategies towards ultra-safe models of safety and protocol-mandated care. However, in order to operate ultra-safe strategies embedded in CPOE and stay on protocol it is essential for clinicians to be thoughtful and show sensitivity to operations in CPOE use. CPOE design can be advanced by better consideration of mechanisms to support interdependencies.
Highlights
There are serious safety risks associated with chemotherapy, often associated with interdependencies in regimens administered over months or years
In order to operate ultra-safe strategies embedded in Computerized provider order entry (CPOE) and stay on protocol it is essential for clinicians to be thoughtful and show sensitivity to operations in CPOE use
We integrated results from interviews and incidents analysis and structured these around interdependencies and risks to medication safety, strategies to deal with these risks, and the role of the CPOE for each strategy
Summary
There are serious safety risks associated with chemotherapy, often associated with interdependencies in regimens administered over months or years. Computerized provider order entry (CPOE) systems are implemented to improve medication safety. Chemotherapy regimens are administered often in combination with other medications and over many months, and errors are often associated with interdependent elements of chemotherapy regimens, such as number of cycles, dose scheduling, cumulative doses, and monitoring [1, 2]. To reduce harm from chemotherapy, risk management strategies must be in place [3], individual patient regimens must be based on documented and referenced protocols [4], and work processes organised with reference to accepted standards [4,5,6,7] and designed to reduce the possibility of error [8, 9]. Computerized provider order entry (CPOE) systems with decision support are a further strategy for improving safety with chemotherapy. Adoption of CPOE for chemotherapy can lag behind adoption of CPOE systems for other medications or in other clinical areas [15]
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