The Chemo Huddle: a Strategy to Minimize Errors and Maximize Chemotherapy Safety

Abstract

The administration of chemotherapy in the pediatric population is a high risk process, requiring safety checks throughout each stage of prescribing, dispensing, and administration. While computerized physician order entry (CPOE) has eliminated many potential and actual errors, many institutions currently use multiple computer applications, or concurrent computer and paper systems, to process chemotherapy orders. Systems that are not integrated pose a safety risk, requiring innovative strategies to minimize error throughout nursing, physician and pharmacy workflow. At our institution, the use of non-interfacing systems was determined to be a factor in two chemotherapy errors. Several strategies were subsequently developed increase safety and strengthen confidence in the chemotherapy process. One strategy is the chemotherapy “huddle”, in which nursing and pharmacy meet daily to review chemotherapy orders. During the huddle, clinicians ensure that medications, number of doses, and administration dates/times are accurate and assigned correctly. An audit tool is completed to track corrections and changes. The huddle takes 5-15 minutes to complete.