Clinical Systems Support Decision-making and Improve Safety

ONCNG Oncology NursingJune 2009
Volume 3
Issue 3

In my 15 years of oncology/hematology nursing experience, I�ve seen many errors and near-errors. No one is exempt from making mistakes, regardless of their experience level, and even a seemingly simple oversight can be dangerous for patients.

In my 15 years of oncology/hematology nursing experience, I’ve seen many errors and near-errors. No one is exempt from making mistakes, regardless of their experience level, and even a seemingly simple oversight can be dangerous for patients. At OnCare Hawaii, patient safety is a high priority for our team of 12 physicians and 3 nurse practitioners. That’s why we recently decided to use IntelliDose®, a computerized physician order entry (CPOE) system, to safely and efficiently manage complex chemotherapy treatments across four sites.

Oncology as we know it is changing. Oncologists and nurses are treating up to three times as many patients as they did only 5 to 7 years ago. They’re also prescribing or administrating what seems like a limitless number of drug combinations, each of which carries a significant risk for adverse reactions. Working in such a stressful, fast-paced environment creates a higher risk for unintended oversights and chemotherapy dosing errors. To minimize, if not eliminate, the potential for such errors, an increasing number of oncology practices are turning to CPOE systems, such as Intellidose.

Benefits of a shared system of record

Training an oncology nurse is no easy feat. It’s absolutely critical that they learn everything about a drug treatment, including how it works, the correct dosing, its side effects, what precautions to take to avoid adverse reactions, how to treat any reactions, and what lab values to monitor. It’s also important for nurses to carefully document every single administration, and the notes must be detailed enough to stand up in court, serving to explain and justify all actions. Because much of a nurse’s learning happens on the job, the high pressure environments of oncology practices provide opportunity for nurses to become well-rounded. As these nurses sharpen their skills, they gain critical understanding of multiple treatment regimens and the knowledge needed to identity deviations in treatment and incorrect dosing.

A CPOE is a powerful tool that automates and standardizes chemotherapy orders, removing the complexity, inefficiency, and potential for error that can result from handwritten chemotherapy orders. Most CPOEs integrate data with existing electronic health record systems, but they can be used as a standalone treatment tool. CPOEs create a shared system of record, tracking every patient visit, drug administration, and cumulative dosing to avoid unnecessary drug toxicity. Their ability to gather and store complex treatment regimens also aid physicians and nurses in making treatment decisions. For example, if patients respond well to a treatment, it might be recorded within the CPOE as a “best practice” and referenced in the care of similar patients.

The need for oncology-specific systems

Oncology-specific CPOEs calculate dosages, provide treatment schedules, and include embedded drug guidelines to prevent oncologists, nurses, and pharmacists from administering or filling harmful prescriptions. Many systems even require a “double sign-off” on every chemotherapy order before it can be administered, and in some cases, a cautionary warning may pop up, alerting the physician that a certain lab value must be checked before the patient can be cleared for treatment. As with any new software implementation, practices must invest resources to launch and maintain a CPOE; however, this investment won’t go unnoticed, and those that make the investment show their commitment and dedication to ensuring quality of care and patient safety.

Once a CPOE is up and running, the benefits are far reaching and start with the standardization of drug administrations. Most physicians write treatment and prescription orders, but nurses hold the responsibility of administering them. When these orders are handwritten, they can be easily misread, transcribed incorrectly, or misinterpreted. Nurses may also misread a drug handbook when rushing to look up instructions and may administer the drug incorrectly or accidentally administer an intravenous push instead of a longer 2-hour administration. CPOEs are an easy treatment-regimen drug resource for oncologists and nurses because they are always up-to-date, containing detailed information and instruction on every cancer drug.

In a manual, paper-based environment, oncologists and nurses use flow sheets to track treatments. If an oversight occurs and a dose is not transcribed as “given,” this could create a risk of extra dosing. Under-dosing can occur just as easily, preventing patients from receiving the level of treatment needed to cure or prolong life. Errors can also happen in manually counting doses. CPOEs ensure that every drug administration is tracked. They allow easy calculation of treatment schedules and document in chart when the next treatment is due. This prevents patients from receiving doses too frequently, which could be harmful. Furthermore, because these computerized systems increase efficiencies, they allow nurses to spend time where it matters most—caring for their patients.

Rowena Yee Hoy, RN, is the clinical practice manager and director of nursing at OnCare Hawaii. She can be reached at

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