Web-based reporting in the outpatient community setting is not only feasible, but it can identify areas that need quality improvement initiatives, according to J. Russell Hoverman, MD, PhD, Vice President of Quality Programs, Texas Oncology, PA, Dallas.
“At ASCO 2007, we presented our 2-year experience with a web-based medication occurrence reporting tool,” said Dr Hoverman at the 2016 ASCO Quality Care Symposium. “We now report the 11-year experience in a single outpatient oncology practice.”
A Rise in Adverse Drug Reactions
Since December 2003, Texas Oncology sites have entered information on medication occurrence reports in an electronic variance reporting tool.
Medication occurrences rose considerably between 2004 and 2014. “The occurrence rate was about 0.33% in 2007, and then things seemed to take off,” he said. “Of course we were interested in why that happened, and adverse drug reactions are a huge reason for this.”
A Culture of Safety
Over 11 years, there were 2,163,249 transactions for a chemotherapy infusion or injection. Of 10,845 medication occurrences, 5143 were adverse drug reactions, and the majority of adverse drug reactions were caused by rituximab (20.9%) and paclitaxel (16.4%). There were 10 deaths over 11 years. Near misses accounted for 16.7% of the unadjusted medication occurrence rate and for 31.8% when adverse drug reactions were excluded.
With these data, Texas Oncology was able to promote an epinephrine protocol for severe drug reactions, eliminate the need for automated external defibrillators (AEDs) at every site, assess prophylactic corticosteroid regimens in taxane administration, determine that there was no geographic association with rituximab reactions, make assessments regarding the cost and toxicity of iron compounds, and target specific drugs for adverse drug reaction risk.
“This comprehensive safety and reporting program creates a culture of conscientiousness and transparency,” said Dr Hoverman. The number of avoided medication occurrences, indicated by the near-miss percentage, reinforces the importance of double-checking. “This is not scientific,” he added. “This is an attempt to create a culture of safety within our sites.”
“Dr Hoverman and his team have worked to embed safety into the structure of their organization and have avoided blame by recognizing the basic principle that ‘to err is human,’” said Deborah Schrag, MD, MPH, Chief, Division of Population Sciences, Dana-Farber Cancer Institute, Boston. “They have built a system that enabled shareable results and data, as well as encouragement of innovation.”
“Dr Hoverman’s data on adverse events for specific drugs should be extremely generalizable,” Dr Schrag added. “About 6 drugs account for the vast majority of adverse events. Why are we using iron dextran? That should be retired. This seems awfully simple, particularly given that we have treatment alternatives.”
“Rituximab and paclitaxel are associated with a much greater likelihood of adverse events when we give them,” Dr Schrag said. “Patients who are treated with these drugs clearly need more intensive nursing care and careful attention to premedication regimens and PRN [as needed] orders, as well as available and well-stocked crash carts with medication for treating these adverse reactions. This is actionable info.”