A risk assessment to identify how errors occur when oral chemotherapies are used by pediatric patients at home (and to propose risk-reduction strategies) relied on input from those primarily in charge of oral chemotherapy use at home—the parents. A total of 18 parents were recruited at three pediatric oncology clinics in high- and low-volume clinics in the northeast and southeast United States.

“Parents identified 69 failure modes that could occur in the process of home use of oral chemotherapy after a change in medication dose,” investigators reported in the Journal of Oncology Practice.¹ The highest-ranked factor was “misunderstanding physician instructions about changes in medication doses, either through misunderstanding on the part of the parent or conflicting instructions being received from different clinicians,” the authors stated. “The second was the unsafe handling of chemotherapy medications at home,” and the third was “the child refusing to take the medication or vomiting the medication for several days.”

Recommended Strategies

Strategies recommended by parents to reduce risks at home “fell into three general categories,” according to the researchers, who listed them as follows:

1. Streamline current processes (eg, issue updated home medication list, have one designated point of clinical contact, bring home caregivers in for doctor visits)

2. Offer additional information/support from clinicians (eg, print or e-mail after-visit summaries, provide virtual help/support via e-mail or Web portal, have a nurse make one or multiple home visits, recommend when to call the doctor about home medication use, provide standard form for parents to take notes during doctor visits, prepare a medication calendar with check boxes)

3. Supply additional information/support via parents (eg, parent-run listserve/chat room or “parent-run WebMD”)

New ASCO/ONS Standards Expected

Parents and other family members are “often unaware” about safe handling practices and “surprised when they hear that there are some issues around that,” Saul N. Weingart, MD, PhD, one of the article’s authors, told The ASCO Post. Dr. Weingart is Vice President for Quality Improvement and Patient Safety at Dana-Farber Cancer Institute, Boston. “Certain oral chemotherapy drugs should not be handled with bare hands; people should be gloved. If you are going to be cutting the pills or pouring liquid, how are you going to make sure the surfaces you cut the pills on, the knife, and the cup are clean and then sanitized afterwards, so that other children are not exposed to the drug?” 

These issues are part of increasing attention to providing education for patients and families about how to use these drugs safely, Dr. Weingart said. “Oral chemotherapy is getting to be a very, very hot topic, and the American Society of Clinical Oncology (ASCO) and Oncology Nursing Society (ONS) are going to be coming out with recommendations regarding standards for prescribing and administering oral chemotherapy.” 

The new ASCO/ONS standards are expected to include guidelines that support safe adherence at home, safe handling practices, monitoring, and other types of patient care “that occurs outside of the normal control of the cancer center.” Dr. Weingart said. “When the ASCO/ONS standards come out, a lot of cancer centers and practices around the country are going to be looking at what they do and thinking about where there are opportunities for improvement.” ■

Disclosure: Dr. Weingart and coauthors reported no potential conflicts of interest.

Reference

1. Walsh KE, Mazor KM, Roblin D, et al: Multisite parent-centered risk assessment to reduce pediatric oral chemotherapy errors. J Oncol Pract 9:e1-e7, 2013.