(1A) Chemotherapy treatment schedule in chart | (1) Old chemotherapy treatment schedule in chart | 6 | Pediatric oncologist did not update schedule in chart | (1) Design standard procedure for changes in chemotherapy treatment schedules | • Regular subject oncology staff meeting • In residents’ work instruction within 2 months | Nurse Supervisor | + |
(2) Chemotherapy treatment schedule misunderstood | 4 | Schedule in language other than Dutch or English | (2) Translate chemotherapy treatment schedules | • Evaluated after 2 months • In residents’ work instruction • Within 2 months inoncologists’ standardprocedures | Supervisor Supervisor Head | + |
| | | | | | | |
(1C) Dose calculation and prescription entry in CPOE by resident | (3) Dose miscalculation by resident | 8 | (1) Workload | (3) Determine minimum number of residents and do not change all residents at the same time | • 6 month test period | Supervisor | +/− |
(2) Frequent paging | (4) Allow residents writing chemotherapy orders without interruption; turn off pagers after 5 pm (after sign out) | • 2 month test period | Resident | – |
(3) Frequent interruption | (5) Write chemotherapy orders in separate room | • 2 month test period | Supervisor | + |
(4) Change in authorized prescription not noticed by nursing staff | 8 | Nursing staff not notified by resident | (6) Install electronically controlled administration system (bar codes) | • Under investigation | Pharmacy | Probably |
(5) Change in prescription not noticed in pharmacy | 8 | Changed prescription not printed out in pharmacy | None, problem is already being solved by IT specialists | | | |
| | | | | | | |
(2A) Prescription received by CPOE | (6) Old dose delivered by pharmacy after change in authorized medication | 8 | Change in authorized prescription not noticed in time by pharmacy | (7) Notify pharmacy by telephone to ensure that changes are processed correctly | • 2 months test period | Pharmacist | + |
| | | | | | | |
(3.1E) Connect medication tube to patient | (7) Impossible to withdraw blood from central venous line | 3 | Positioned extravascularly | (8) Physician has to evaluate the line | • In residents’ work instruction within 2 months • Nurses informed within 2 months | Supervisor Nurse | + |
| | | | | | | |
(3.2E) Put in and check iv needle | (8) Extravasation of peripheral venous access | 6 | Resident not aware of risk of extravasation of vincristine | (9) Only pediatric oncologist allowed administrating vincristine via peripheral intravenous access | • Standard procedure within 6 months • Nurses informed within 1 month • In residents’ work instruction within 2 months | Supervisor Nurse Supervisor | + |