Using Standards Balances Technology Advancements With Critical Thinking

Patient Case Study 1

E.W. was admitted to the inpatient hospital unit for his third cycle of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) for diffuse large B-cell lymphoma. On admission, the nursing assistant obtained E.W.'s body measurements and entered them in the electronic chart. The advanced practice provider wrote chemotherapy orders based on the body measurements entered in the system, and the attending oncologist subsequently approved them. Staff pharmacists mixed the chemotherapy and delivered the first medication to be administered to the unit. As part of the chemotherapy verification policy, two chemotherapy-approved nurses verified the accuracy of the body surface area calculation. During the process, the nurses realized that the body weight was entered incorrectly into the system, therefore creating an error in chemotherapy dosing.

Patient Case Study 2

C.S. presented to her outpatient chemotherapy infusion suite to begin her fourth cycle of adjuvant docetaxel and cyclophosphamide for breast cancer. Doses were prepared based on the body surface area calculated from measurements entered into the medical records for prior cycles of chemotherapy. On admission, the primary nurse verified whether current body measurements matched what was currently entered into the medical record, and he noticed a significant weight change. The nurse notified the provider and pharmacist so a conversation could ensue about whether a dosing change was needed.

In both scenarios, significant patient errors could have occurred had thorough independent verification of all chemotherapy order elements not been conducted. The ability to autocalculate body surface area based on height and weight entered into the system does not replace the need for independent verification of measurements entered and calculations based on these measurements. Critical thinking and implementation of standards of care in their entirety reduces the risk for error and patient harm.

Through many forums, ONS members bring concerns and areas of question to our attention while they’re using standards at the point of care, and the need for verification of body surface area and other calculations that determine chemotherapy dosing was one of them. The American Society of Clinical Oncology/ONS Chemotherapy Administration Safety Standards call for at least weekly height and weight measurement while patients are in the healthcare setting and when appropriate to treatment plan as well as for two chemotherapy-approved professionals to independently verify dose calculations.  Additionally, the ONS Documentation Standards for Cancer Treatment outline the need to document height and weight throughout chemotherapy treatment.

Although oncology treatment standards facilitate best practice and provide a framework on which policies and procedures can be built, they must be interpreted accurately and implemented thoroughly to optimize care and patient safety. ONS clinical staff are available at clinical@ons.org for help in interpreting standards of care.