Start using a checklist,PRONTO: Recommendation for a standard review process for chemotherapy orders

Abstract

Chemotherapy order review by pharmacists requires careful attention to many details, and serious consequences can occur if errors are made. Other high-risk industries have long used checklists to improve accuracy and reduce the risk of errors. Despite the recent expansion of checklist use in other areas of medicine, there is currently no published evidence that checklists are being widely used by pharmacists in the evaluation of chemotherapy orders. This article explains a flexible checklist called PRONTO (Patient, Regimen, Organ Function, Numbers, Toxicity, Order Verification) that has been successfully used by pharmacists in variety of practice settings in two academic centers in North Carolina. Proposed benefits of using a checklist in order review include standardization of review for better communication between collaborating pharmacists, a training tool for new or cross-training pharmacists, and an educational tool for students.

Keywords

Checklist chemotherapy orders order evaluation standardized process

Get full access to this article

View all access options for this article.

References

Hales

Pronovost

. The checklist—a tool for error management and performance improvement. J Crit Care 2006; 21: 231–235.

Gawande

. The checklist manifesto: how to get things right, 1st ed. New York, NY: Metropolitan Books, 2010.

Meisenberg

Wright

Brady-Copertino

. Reduction in chemotherapy order errors with computerized physician order entry. J Oncol Pract 2014; 10: e5–e9.

Cohen

Anderson

Attilio

et al.

Preventing medication errors in cancer chemotherapy. Am J Health-Syst Pharm 1996; 53: 737–746.

Goldspiel

Hoffman

Griffith

et al.

ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Am J Health-Syst Pharm 2015; 72: e6–e35.

Finley

Balmer

. American Society of Hospital Pharmacists. Concepts in oncology therapeutics, Bethesda, MD: American Society of Hospital Pharmacists, 1998.

Carrington

Stone

Koczwara

et al.

Development of guidelines for the safe prescribing, dispensing and administration of cancer chemotherapy. Asia Pac J Clin Oncol 2010; 6: 213–219.

Neuss

Polovich

McNiff

et al.

2013 Updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy. J Oncol Pract 2013; 9: 5s–13s.

Thomassen

Storesund

Søfteland

et al.

The effects of safety checklists in medicine: a systematic review. Acta Anaesthesiol Scand 2014; 58: 5–18.

10.

Haynes

Weiser

Berry

et al.

A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360: 491–499.

11.

White

Trbovich

Easty

et al.

Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model. Qual Saf Health Care 2010; 19: 562–567.

12.

Akcasu

Oswald

. A systematic approach to preparing for chemotherapy administration. J Pediatr Oncol Nurs 1991; 8: 136–138.

13.

Dobish

Shultz

Neilson

et al.

Worksheets with embedded checklists support IV chemotherapy safer practice. J Oncol Pharm Pract 2016; 22: 142–150.

14.

Duong

. Chemotherapy order review and documentation: let’s put the anDROIDs to work!. J Oncol Pharm Pract 2002; 8: 55–71.

15.

Robert S and Mancini P. Chemotherapy Administration Sequence: a review of the literature and creation of a sequencing chart, http://jhoponline.com/jhop-issue-archive/2011-issues/march-vol-1-no-1/13240-top-13240 (2011, accessed 22 May 2015).

16.

Superfin

Iannucci

Davies

. Commentary: oncologic drugs in patients with organ dysfunction: a summary. Oncologist 2007; 12: 1070–1083.

17.

Launay-Vacher

Oudard

Janus

et al.

Prevalence of renal insufficiency in cancer patients and implications for anticancer drug management: the renal insufficiency and anticancer medications (IRMA) study. Cancer 2007; 110: 1376–1384.

18.

Launay-Vacher

Chatelut

Lichtman

et al.

Renal insufficiency in elderly cancer patients: International Society of Geriatric Oncology clinical practice recommendations. Ann Oncol 2007; 18: 1314–1321.

19.

Aapro

Launay-Vacher

. Importance of monitoring renal function in patients with cancer. Cancer Treat Rev 2012; 38: 235–240.

20.

Winter

Guhr

Berg

. Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation. Pharmacotherapy 2012; 32: 604–612.

21.

Naesens

Kuypers

DRJ

Sarwal

. Calcineurin inhibitor nephrotoxicity. Clin J Am Soc Nephrol 2009; 4: 481–508.

22.

Launay-Vacher

. Cancer and the kidney: individualizing dosage according to renal function. Ann Oncol 2013; 24: 2713–2714.

23.

Weng

Zhang

Peng

et al.

Pharmacogenetics and pharmacogenomics: a bridge to individualized cancer therapy. Pharmacogenomics 2013; 14: 315–324.

24.

Marsh

Hoskins

. Irinotecan pharmacogenomics. Pharmacogenomics 2010; 11: 1003–1010.

25.

Rodríguez-Vicente

Lumbreras

Hernández

et al.

Pharmacogenetics and pharmacogenomics as tools in cancer therapy. Drug Metab Pers Ther 2016; 31: 25–34.

26.

Health C for D and R. In Vitro Diagnostics – List of Cleared or Approved Companion Diagnostic Devices (In Vitro and Imaging Tools), www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm301431.htm (accessed 4 January 2017).

27.

Del Re

Citi

Crucitta

et al.

Pharmacogenetics of CYP2D6 and tamoxifen therapy: Light at the end of the tunnel?

Pharmacol Res 2016; 107: 398–406.

28.

Relling

Evans

. Pharmacogenomics in the clinic. Nature 2015; 526: 343–350.

29.

Warr

Hird

DeAngelis

et al.

Baseline blood work before initiation of chemotherapy: what is safe in the real world?

J Oncol Pract 2013; 9: e182–e185.

30.

Duong

Loh

J-Y

. Laboratory monitoring in oncology. J Oncol Pharm Pract 2006; 12: 223–236.

31.

Griggs

Mangu

Anderson

et al.

Appropriate chemotherapy dosing for obese adult patients with cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2012; 30: 1553–1561.

32.

Ivy SP, Zwiebel J and Mooney M. Follow-up for information letter regarding AUC-based dosing of carboplatin. https://ctep.cancer.gov/content/docs/carboplatin_information_letter.pdf (accessed 22 October 2010).

33.

Bott A, Fahrenbruch R, Gilmore S, et al. Dose rounding of biologic and cytotoxic anticancer agents A position statement of the Hematology/Oncology Pharmacy Association, www.nccn.org/professionals/OrderTemplates/PDF/HOPA.pdf (2017, accessed 3 July 2017).

34.

Jarkowski

Nestico

Vona

et al.

Dose rounding of ipilimumab in adult metastatic melanoma patients results in significant cost savings. J Oncol Pharm Pract 2014; 20: 47–50.

35.

O’Neil

Allen

Spigel

et al.

High incidence of cetuximab-related infusion reactions in Tennessee and North Carolina and the association with atopic history. J Clin Oncol 2007; 25: 3644–3648.

36.

Haller

Cassidy

Clarke

et al.

Potential regional differences for the tolerability profiles of fluoropyrimidines. J Clin Oncol 2008; 26: 2118–2123.

37.

Smith

Bohlke

Lyman

et al.

Recommendations for the use of WBC growth factors: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2015; 33: 3199–3212.

38.

Einhorn

Rapoport

Navari

et al.

2016 Updated MASCC/ESMO consensus recommendations: prevention of nausea and vomiting following multiple-day chemotherapy, high-dose chemotherapy, and breakthrough nausea and vomiting. Support Care Cancer 2017; 25: 303–308.

39.

Basch

Prestrud

Hesketh

et al.

Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2011; 29: 4189–4198.

40.

Hensley

Hagerty

Kewalramani

et al.

American Society of Clinical Oncology 2008 clinical practice guideline update: use of chemotherapy and radiation therapy protectants. J Clin Oncol 2009; 27: 127–145.

41.

Piccart

Klijn

Paridaens

et al.

Corticosteroids significantly delay the onset of docetaxel-induced fluid retention: final results of a randomized study of the European Organization for Research and Treatment of Cancer Investigational Drug Branch for Breast Cancer. J Clin Oncol 1997; 15: 3149–3155.

42.

Semb

Aamdal

Oian

. Capillary protein leak syndrome appears to explain fluid retention in cancer patients who receive docetaxel treatment. J Clin Oncol 1998; 16: 3426–3432.

43.

Smith

Khatcheressian

Lyman

et al.

2006 Update of recommendations for the use of white blood cell growth factors: an evidence-based clinical practice guideline. J Clin Oncol 2006; 24: 3187–3205.

44.

Freifeld

Bow

Sepkowitz

et al.

Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis 2011; 52: e56–e93.

45.

Tomblyn

Chiller

Einsele

et al.

Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant 2009; 15: 1143–1238.

46.

Chanan-Khan

Sonneveld

Schuster

et al.

Analysis of herpes zoster events among bortezomib-treated patients in the phase III APEX study. J Clin Oncol 2008; 26: 4784–4790.

47.

Lenz

H-J

. Management and preparedness for infusion and hypersensitivity reactions. Oncologist 2007; 12: 601–609.

48.

Coiffier

Altman

Pui

C-H

et al.

Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol 2008; 26: 2767–2778.

49.

Jones

Will

Jackson

et al.

Guidelines for the management of tumour lysis syndrome in adults and children with haematological malignancies on behalf of the British Committee for Standards in Haematology. Br J Haematol 2015; 169: 661–671.

50.

Herrington

Dinh

. Fixed, low-dose rasburicase for the treatment or prevention of hyperuricemia in adult oncology patients. J Oncol Pharm Pract 2015; 21: 111–117.

51.

Meyer

Raymond

Rodrigue

CMJ

. Development and Evaluation of a Checklist for Medication Order Review by Pharmacists. Can J Hosp Pharm 2011; 64: 199–206.