GRP-120 Multidisciplinary Intervention: Intrathecal and Intraventricular Chemotherapy in Paediatrics

Background A communications system was designed after notification of two errors in two months, in intrathecal and intraventricular chemotherapy in paediatric oncohaematology: prescribing by protocol, consultation sheet standardised and computerised; transcription using the Farmis integrated system for chemotherapy and preparation centralised in the pharmacy after standardisation, and administration with a double cheque. Functions were established and detailed in each process to all groups involved. Purpose To conduct a retrospective observational descriptive study to cheque compliance with the intrathecal and intraventricular rules at each level: prescription, transcription, preparation, distribution and administration and to analyse any change in the errors made with intrathecal and intraventricular chemotherapy before and after the new system was implemented. Materials and Methods Each of the processes in the system was tracked, during the year after the intervention – July 2011. Prescriptions were analysed through electronic medical records, Farmis, nursing and pharmacy records. Medicines error reporting to the Safety Commission was monitored during the year after the implementation. The error rate was determined by comparing the two months prior to the intervention. Results 167 prescriptions were checked, 133 intrathecals and 34 intraventriculars. The professionals involved were monitored 100% in all processes, except the administration checklist by neurosurgeons, which was only 62.5% checked. The error rate reported by number of prescriptions went from 0.14 in the previous two months to 0.006 in the year after intervention. Conclusions There has been high system monitoring by all professionals involved. The number of medicines errors became lower in the post-intervention period. Thus, centralization and standardisation of intrathecal and intraventricular chemotherapy has helped increase patient safety. No conflict of interest.