Learning from near misses: Addressing nursing chemotherapy verification fatigue.

Abstract

70 Background: Administration of chemotherapy is high-risk, requiring multiple safety checks, including pre-treatment laboratory value verification by nursing. A recent series of near misses in our event reporting system highlighted that nurses verified chemotherapy orders with pending pre-treatment or abnormal labs, such as grade 2 hyperbilirubinemia and grade 4 neutropenia. Such laboratory results would normally require holding or modifying planned treatment doses. Methods: Nurses treating patients in the outpatient chemotherapy infusion units were surveyed regarding barriers to pre-treatment lab verification. A team of clinicians, nurses, and pharmacists outlined a process map of the order verification process from acknowledging patient assignment and looking at patient oncologic history to sending the physician order to pharmacy. Pharmacists collected baseline data by tracking near-miss incidents. Results: The survey response rate of outpatient treatment nurses was 18 of 32 (56%). Nurses ranked inconsistent notation of treatment criteria in orders, long lab processing time, and patient frustration with a long wait as the most common barriers to lab verification. At baseline, in six non-consecutive weeks from August-October 2016, 31 of 947 (3%) orders were inappropriately verified by nursing in which pre-treatment lab results were pending or lab results did not meet parameters in the chemotherapy order. The team’s aim is by February 1, 2017, to reduce the number of chemotherapy orders sent to pharmacy without proper lab verification by 50%. Conclusions: Chemotherapy verification fatigue, specifically pre-treatment lab near misses, was identified as an area for improvement from recent patient safety reports. Barriers for nurses include inconsistent notation of treatment criteria in orders, long lab processing time, and patient frustration with a long wait. Interventions are underway to improve nursing adherence to pre-treatment lab verification.