Guidance for the Network Review of Chemotherapy Errors

Transcription

1 Guidance for the Network Review of Chemotherapy Errors For approvals and version control see Document Management Record on page 8 Doc Ref: AngCN-CCG-C31 Approved and published: March 2013 Page 1 of 8

2 Table of Contents 1 Introduction Contents Purpose and intent of this process Summary of the Outline Process Administration Errors Summary of the Outline Process Prescribing and Dispensing Errors... 4 Appendix A - AngCN Chemotherapy Incident Reporting Form for Chemotherapy Administration Errors... 5 Appendix B Chemotherapy Prescribing Errors Recording Form... 6 Appendix C NPSA Incident Grading Definitions and Risk Matrix Evidence of Agreement... 8 Approved and published: March 2013 Page 2 of 8

3 1 Introduction The Manual for Cancer Services revised Chemotherapy Measures, published in April 2011 specify that the network Chemotherapy Board should review the reported errors and resulting actions of the Trusts Clinical Chemotherapy Services (CCS), at least annually. The purpose of this document is to provide the AngCN Trusts and AngCN Chemotherapy Board with guidance on the reporting of chemotherapy errors across the Anglia Cancer Network Whilst this document has been prepared by the AngCN Lead Pharmacist and is subject to AngCN Chemo Board discussion and agreement to ensure equity of reporting and inclusion of all network Trusts, sign-off of this guidance document is not in itself a Peer Review requirement. It is important to note that this document has been produced in line with the current NPSA Chemotherapy Error Reporting guidance, the link to which is provided within Appendix C on page 7 of this document. 2 Contents 1. The outline process for the recording and reporting of administration errors, 2. The outline process for the recording and reporting of prescribing and dispensing errors, 3. A suggested template for administration errors, 4. An example template for prescribing errors, 5. The NPSA Chemotherapy Error Reporting guidance. 3 Purpose and intent of this process The purpose of this process is to assist the AngCN Chemotherapy Board in understanding Chemotherapy error trends to ensure that we have and continue to have a safe service across the network. The reported information will not be used for performance management purposes. 4 Summary of the Outline Process Administration Errors All Chemotherapy Administration errors categorised as moderate and above (including near misses, moderate, major or catastrophic, SUIs and never events) should be reviewed at each of the Chemotherapy Nurses Group meetings. From these reviews, establish any trends and, if appropriate recommend corrective actions. Agree the key messages that should be taken to the AngCN Chemotherapy Board in the June meeting of each year. The suggested form on which all Chemotherapy Administration errors should be recorded is attached as Appendix A to this guidance. Approved and published: March 2013 Page 3 of 8

4 5 Summary of the Outline Process Prescribing and Dispensing Errors The majority of prescribing errors will be detected at the point of the pharmacist clinical verification check. Many of these will be minor errors (e.g. small date changes) but some will be more significant and potentially harmful if they were to reach the patient. These should be recorded by each Acute Trust and monitored by the Network NOPG. In general these are errors requiring a pharmacist intervention and correction by the prescriber are: 1. Incorrect Patient 2. Regimen or Drug Error a) Incorrect regimen or drug prescribed b) Drug not indicated for tumour site c) Incorrect dosage form d) Incorrect route e) Incorrect diluents 3. Dosing Error a) Wrong dose b) BSA miscalculation c) CrCl miscalculation d) Incorrect infusion rate 4. Protocol Violation a) Wrong dosing interval b) Incorrect dose modification c) Missing supportive care drugs d) Clinically significant drug interaction e) Cumulative dose exceeded 5. Other error deemed significant The staff group that detected the error and the stage of the chemotherapy pathway at which it was detected should also be recorded, and all data collected on the attached spreadsheet (Appendix B). Dispensing and manufacturing errors made during the supply of chemotherapy from the pharmacy should be monitored and recorded by in-house and regional pharmacy dispensing error databases. Approved and published: March 2013 Page 4 of 8

5 Appendix A - AngCN Chemotherapy Incident Reporting Form for Chemotherapy Administration Errors (Trust to AngCN Network Chemotherapy Group) Trust: Trust Incident Report Form Reference: Description of Incident: Cause: Date of Incident: Location of Incident: Grade: (See NPSA Grading Definitions Overleaf) What Happened: Moderate Major Catastrophic/SUI SUI Grade 1 SUI Grade 2 Outcome: Was the patient affected/injured: Yes No Name of Person(s) completing the form: Lead Nurse/Pharmacist Signature: Name: Date: For AngCN Use Only: AngCN Network Chemotherapy Group Review Date: Signature of AngCN Network Chemotherapy Group Chair: AngCN Reference Number: The above reporting form is designed to assist those network Trusts who may not already have a form of this type in place. Approved and published: March 2013 Page 5 of 8

6 Appendix B Chemotherapy Prescribing Errors Recording Form The following tables containing the codes and a recording form template for prescribing errors are examples for reference only. The formalised document under which these are available is AngCN-CCG-C34 Prescribing Errors Recording Form available on the AngCN Website as follows: Approved and published: March 2013 Page 6 of 8

7 Appendix C NPSA Incident Grading Definitions and Risk Matrix Catastrophic or SUI Moderate Moderate injury requiring professional intervention Major Major injury leading to long term incapacity/disability Incident leading to death or unexpected death Multiple permanent injuries or irreversible health effects An event which impacts on a large number of patients SUI Grade 1 SUI Grade 2 Avoidable or unexplained death Requiring time off work for 4-15 days Increase in length of hospital stay by 4-15 days An event which impacts on a small number of patients Wrong drug or dosage administered with potential adverse effects Requiring time of work for > 14 days Increase in length of hospital stay by > 15 days Mismanagement of patient care with long-term effects Wrong drug or dosage administered with adverse effects Data loss and information security (DH Criteria level 2, see Information Resource) Poor discharge planning causes harm to patient Research and clinical trials Never event* * Never Events are defined as events which should never occur under any circumstances. Examples of these are: Chemotherapy given to the wrong patient Wrong drug given to the wrong patient Drug given by wrong route The associated NPSA Risk Matrix for Risk Managers guidance is available on the NPSA website, the weblink for which is as follows: The NPSA s main website can be found via this link: Approved and published: March 2013 Page 7 of 8

8 6 Evidence of Agreement Document management Document ratification and history Approved by: Date approved: Review period: Authors: Matthew Small (NOPG Chair) and Hugo Ford (SACT Chair) 26 February 2013 Two years AngCN Chemotherapy Nurses Group Matthew Small, Chair of the Network Oncology Pharmacy Group Version number as approved and published: 1 Monitoring the effectiveness of the Process Date placed on electronic library: Document Owner: Unique identifier no.: March 2013 Anglia Cancer Network, Tel: ; AngCN-CCG-C37 a) Process for Monitoring compliance and Effectiveness - Review of compliance as determined by audit. Any non compliance to be presented by PQ Manager to the AngCN Business Meeting on an annual basis the minutes of this meeting are retained for a minimum of five years. b) Standards/Key Performance Indicators This process forms part of a quality system working to, but not accredited to, International Standard BS EN ISO 9001:2008. The effectiveness of the process will be monitored in accordance with the methods given in the quality manual, AngCN-QM. Equality and Diversity Statement This document complies with the Suffolk PCT Equality and Diversity statement an EqIA assessment is available on request to Anglia Cancer Network PQ Manager, Gibson Centre, Exning Road, Newmarket, CB8 7JG. Disclaimer It is your responsibility to check against the electronic library that this printed out copy is the most recent issue of this document. Approved and published: March 2013 Page 8 of 8