Managing chemotherapy risks : Learning from medication errors and developing a national knowledge source for chemotherapy regimens

The basics in cancer treatment are surgery, radiation therapy, and treatment with cancer drugs, often combined. Chemotherapy regimens that define the drugs used, the dosage, the frequency and duration of drug administration, have been developed and used for different cancer diagnoses. Several healthcare professionals are involved in the treatment: the physician prescribing the drugs, the pharmacist preparing or dispensing the drugs, and finally, the nurse or the patient administering the drugs. Chemotherapy errors that can occur during the treatment represent potential risks for severe patient harm. The aims of this PhD thesis were to increase knowledge about serious medication errors (MEs) in chemotherapy and to develop, implement, and evaluate a national knowledge source for chemotherapy regimens (an e-library) that can support healthcare professionals and mitigate patient safety risks.The characteristics of MEs with parenteral cytotoxic drugs were identified in a retrospective qualitative analysis of 60 cases reported to the Swedish national incident reporting systems 1996-2008. The drugs most involved were fluorouracil, carboplatin, and cytarabine. The largest ME categories included too high doses originating from prescribing, and the wrong drug used during preparation or prescription. Twenty-five of the 60 MEs occurred when physicians were prescribing. Another 25 occurred within the pharmacies. The remaining 10 MEs occurred when the nurses prepared or administered the drug. All the drugs with MEs that occurred during prescription were delivered to the patients. The consequences were especially severe in these cases, including death and harm to the patients. The general failure types (GFTs) and active failures were identified in the 60 cases to better understand why these errors happened. The most frequently encountered GFTs were in Defences (e.g., missed double checking of the patient’s or the drug’s identity) and Procedures (e.g., routines that were lacking or insufficient). Working conditions were a common denominator, often underlying the MEs. Examples were high workloads, and low staffing.A national e-library for chemotherapy regimens with standardised nomenclature and content was developed in close co-operation with healthcare professionals in an iterative process within the Swedish Regional Cancer Centres. The national e-library is a knowledge source containing updated regimens and other supportive information based on the latest evidence, available at: https://kunskapsbanken.cancercentrum.se. To ensure that the design and content complied with the users’ needs, the usage and usability of the national e-library were evaluated using mixed methods. Statistics from the website show an average of just over 2,500 visits and 870 unique visitors per month. The web survey, with 292 answers, showed that the visitors were mainly physicians and nurses. Almost 80% searched for regimens, and 90% found what they were looking for and were satisfied with their visit. An expert evaluation showed that the e-library follows many existing design principles. Qualitative interviews with 4 nurses, 3 physicians, and 3 pharmacists revealed various ways to use the information in the regimens. Users have different needs depending on their profession and their workplace, and the e-library can support these different needs. The national e-library was used in the intended way, and the users were able to interact without any problems. The research in this thesis shows that it is of utmost importance to minimise the potential for errors in the prescribing stage and that a common denominator behind the errors often was working conditions. Today’s Swedish national e-library for chemotherapy regimens contains information based on the latest evidence, is embedded in a national quality system, and contributes to organisational and national learning, ultimately supporting healthcare professionals in managing chemotherapy risks

User evaluation of a national e-library for standardized chemotherapy regimens

An e-library for standardized chemotherapy regimens has been developed and is, since 2015, available as a national resource for healthcare staff and patients in cancer treatment in Sweden. The library was developed in a user-centered design process and is now evaluated to understand how it is used and if it is used in the intended way. This paper presents the e-library in brief together with preliminary results from the ongoing user evaluation, including results from a web survey, web page statistics, and a heuristic evaluation to identify usability issues. The evaluation is a vital part in assuring that the library works as a patient safety barrier, matches the users’ needs, and that it does not have design flaws that could introduce new risks in the already complex chemotherapy process. The results indicate that the library is being used in the intended way and the users do not have any problems interacting with it. With a broad national usage, the standardized chemotherapy regimens e-library can be a source for organizational and national learning, and a source for continuous improvement of cancer care in Sweden

Performance of sulfhydryl boron hydride in patients with grade III and IV astrocytoma: a basis for boron neutron capture therapy

This study investigated the rationale of boron neutron capture therapy (BNCT) for the treatment of Grade III and IV astrocytoma. The European Community joint research program on BNCT plans to use sulfhydryl boron hydride (BSH) in clinical trials. The work presented here, examines the performance of BSH in eight patients with Grade III and IV astrocytoma using a measurement technique which precisely correlates the boron uptake with the histology of the tumor and the peritumoral brain. Astrocytomas are exceptionally heterogeneous and spread migrating tumor cells into the surrounding brain. The patients were infused with 50 mg BSH per kilogram of body weight at 12, 18, 24 or 48 hours before surgery. At the time of operation, specimens were obtained of the tumor, skin, muscle, dura, blood, urine, and, when surgically possible, the brain adjacent to tumor. In three patients the intracellular boron distribution was investigated by subcellular fractionation. The blood clearance was biphasic with half-lives of 0.6 and 8.2 hours. After 3 days, approximately 70% of the dose injected was excreted in the urine. The maximum boron concentration in the tumor was 20 ppm, 12 hours after the infusion. The tumor-to-blood ratios ranged between 0.2 and 1.4, with the highest values after 18 to 24 hours. In the brain specimens the boron concentration never exceeded 1 ppm. This work confirms a selective uptake of boron in the tumor compared to the surrounding brain and that boron, to some extent, is incorporated in the tumor cells