2.50
Hdl Handle:
http://hdl.handle.net/10755/164777
Category:
Abstract
Type:
Presentation
Title:
When Prevention Fails, Policy for Accidental Chemotherapy Overdose
Author(s):
Moore, Joan; Grasso, Judith; Barbarotta, Lisa; Nelson, Wendelin; Fischer, David S.
Author Details:
Joan Moore, MN, APRN, AOCN, Oncology Nursing Education Coordinator, Yale-New Haven Hospital, New Haven, Connecticut, USA, email: joan.moore@ynhh.org; Judith Grasso, MSN, RN, AOCN; Lisa Barbarotta, MSN, RN, AOCNS; Wendelin Nelson, PharmD, BCOP; and David S. Fischer, MD
Abstract:
Clinical/Evidence Based Practice: Enormous effort has been placed on prevention of chemotherapy error, emphasizing the safety of systems to reduce the chance of human error. Despite best efforts, errors have occurred with tragic consequences. Following a fatal fluorouracil error in Canada, the root cause analysis was published. One of the contributing factors cited was lack of a coordinated, rapid response to the error, in order to mitigate damage. Examination of our chemotherapy processes revealed potential risk to patients if immediate overdose actions were not clearly delineated. Literature review and querying multiple institutions did not identify adequate, recommended policies. As a result, the purpose of this work was to develop a policy for chemotherapy overdose to provide a rapid response and minimize morbidity and mortality. A policy to address immediate actions for chemotherapy overdose was developed. Chemotherapy overdose was defined as a dose administered that was significantly larger than prescribed, given at a significantly shorter interval than prescribed, or infused too rapidly. Failure to appropriately dose-reduce chemotherapy, and omission or delay of rescue medications, were included in the overdose definition. Immediate patient evaluation considerations were established. Notification of appropriate personnel was defined. Responsibility for patient and family disclosure was determined. Instructions to access Micromedex Poisindex Summary were provided along with information on how to contact the state Poison Control Center. A table to guide administration of possible antidotes was developed including potential interventions for chemotherapy overdose and required monitoring. Anticipating that most side effects would be amplified, recommendations for lab work, hydration and infection assessments were defined. Treatment and monitoring recommendations for agents known to cause specific organ toxicity were established. Parameters for ongoing monitoring were identified. Documentation included; notifications, assessment of anticipated side effects, treatment plan, level of monitoring and discharge instructions. Availability of a chemotherapy overdose policy provides a level of safety for our patients that previously did not exist. Treatment to decrease morbidity and mortality would be initiated without delay. It is essential to recognize and address potential vulnerability to insure safe practice. Publication of a tragic error elsewhere forced us to be more proactive and provide a clearly defined, rapid response for chemotherapy overdose.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
2009
Conference Name:
34th Annual Oncology Nursing Society Congress
Conference Host:
Oncology Nursing Society
Conference Location:
San Antonio, Texas, USA
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.type.categoryAbstracten_US
dc.typePresentationen_GB
dc.titleWhen Prevention Fails, Policy for Accidental Chemotherapy Overdoseen_GB
dc.contributor.authorMoore, Joanen_US
dc.contributor.authorGrasso, Judithen_US
dc.contributor.authorBarbarotta, Lisaen_US
dc.contributor.authorNelson, Wendelinen_US
dc.contributor.authorFischer, David S.en_US
dc.author.detailsJoan Moore, MN, APRN, AOCN, Oncology Nursing Education Coordinator, Yale-New Haven Hospital, New Haven, Connecticut, USA, email: joan.moore@ynhh.org; Judith Grasso, MSN, RN, AOCN; Lisa Barbarotta, MSN, RN, AOCNS; Wendelin Nelson, PharmD, BCOP; and David S. Fischer, MDen_US
dc.identifier.urihttp://hdl.handle.net/10755/164777-
dc.description.abstractClinical/Evidence Based Practice: Enormous effort has been placed on prevention of chemotherapy error, emphasizing the safety of systems to reduce the chance of human error. Despite best efforts, errors have occurred with tragic consequences. Following a fatal fluorouracil error in Canada, the root cause analysis was published. One of the contributing factors cited was lack of a coordinated, rapid response to the error, in order to mitigate damage. Examination of our chemotherapy processes revealed potential risk to patients if immediate overdose actions were not clearly delineated. Literature review and querying multiple institutions did not identify adequate, recommended policies. As a result, the purpose of this work was to develop a policy for chemotherapy overdose to provide a rapid response and minimize morbidity and mortality. A policy to address immediate actions for chemotherapy overdose was developed. Chemotherapy overdose was defined as a dose administered that was significantly larger than prescribed, given at a significantly shorter interval than prescribed, or infused too rapidly. Failure to appropriately dose-reduce chemotherapy, and omission or delay of rescue medications, were included in the overdose definition. Immediate patient evaluation considerations were established. Notification of appropriate personnel was defined. Responsibility for patient and family disclosure was determined. Instructions to access Micromedex Poisindex Summary were provided along with information on how to contact the state Poison Control Center. A table to guide administration of possible antidotes was developed including potential interventions for chemotherapy overdose and required monitoring. Anticipating that most side effects would be amplified, recommendations for lab work, hydration and infection assessments were defined. Treatment and monitoring recommendations for agents known to cause specific organ toxicity were established. Parameters for ongoing monitoring were identified. Documentation included; notifications, assessment of anticipated side effects, treatment plan, level of monitoring and discharge instructions. Availability of a chemotherapy overdose policy provides a level of safety for our patients that previously did not exist. Treatment to decrease morbidity and mortality would be initiated without delay. It is essential to recognize and address potential vulnerability to insure safe practice. Publication of a tragic error elsewhere forced us to be more proactive and provide a clearly defined, rapid response for chemotherapy overdose.en_GB
dc.date.available2011-10-27T12:06:49Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T12:06:49Z-
dc.conference.date2009en_US
dc.conference.name34th Annual Oncology Nursing Society Congressen_US
dc.conference.hostOncology Nursing Societyen_US
dc.conference.locationSan Antonio, Texas, USAen_US
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.-
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