Detection, Classification, and Correction of Defective Chemotherapy Orders Through Nursing and Pharmacy Oversight

Objective: To describe nursing and pharmacy detection, classification and correction of defects in chemotherapy orders created by computerized practitioner order entry (CPOE). Methods: Chemotherapy cycle orders were prospectively evaluated by the pharmacy before preparation, then by nursing before administration. Data gathered included the nature of defects, use of regimen-specific templates, and patient impact. Results: Pharmacy recognized problems with orders in 36% of 1082 cycles. Incomplete orders comprised 17% (missing cycle number 12.5%; other items 4%); an additional 17% were totally absent. Incorrect orders were identified in 6% (inaccurate antineoplastic dose calculation 2.4%; other items 3.5%). Incomplete orders were more likely to have incorrect items (11.6% versus 3.5%, P < 0.001). Order templates (76% of cycles) were associated with fewer overall problems, incomplete orders (both P < 0.001), and incorrect items (P = 0.045). Nursing recognized problems with 14.6% of cycle orders, again most commonly incompleteness (missing antiemetic 3.4%; missing antineoplastic 2.8%; totally absent, 7%). Nursing detected fewer cycles with problems and overall missing items, but more instances of missing antiemetics (P < 0.001) despite prior pharmacy review. Nursing identified incorrect orders in 5.4% (antineoplastic dose 4.1%; antineoplastic drug 2.5%) and classified 4% of cycles as having an error ("near miss" 3.3%; more serious error 0.6%). Conclusions: Defects in chemotherapy orders are common despite the relatively low error rate. The predominant defect-incomplete orders-was associated with incorrect items. Even with computerized practitioner order entry and standardized order templates, sequential pharmacy and nursing review remain critical to reducing order defects.