Automated parenteral chemotherapy dose-banding to improve patient safety and decrease drug costs.

PURPOSE: To improve patient safety and reduce drug waste through implementation of automated parenteral chemotherapy dose-banding within an electronic health record. METHODS: Parenteral chemotherapy dose-rounding practices were transitioned from a manual, pharmacist-driven workflow to an automated process within the electronic health record. Initial medications transitioned included bevacizumab, rituximab, and trastuzumab. Dose-banding tables were built to standardize rounding within a 10% parameter and then subsequently incorporated into the electronic health record after receiving multidisciplinary approval. Following implementation, a retrospective chart review was performed to compare drug and associated cost savings with manual dose-rounding and automated dose-banding. Medication safety improvements were measured by comparing the change in the number of clicks needed for pharmacist verification as well as by evaluation of submissions to our event reporting system. RESULTS: After implementing automated parenteral chemotherapy dose-banding, reported medication errors associated with the parenteral chemotherapy rounding process decreased. The number of event submissions related to incorrect rounding decreased from four submissions in the pre-implementation period to zero in the post-implementation period. Automation saved pharmacists at least 9,297 additional clicks and 11,363 additional keystrokes and also led to notable increases in total drug savings as well as drug cost savings. CONCLUSION: Overall safety of our parenteral chemotherapy ordering processes within our electronic health record was improved after the implementation of automated dose-banding. By standardizing the administered doses for three chemotherapy agents, we were also able to increase total drug savings and associated drug cost savings.

Creation of a certification requirement for pharmacists in direct patient care roles.

PURPOSE: Steps taken by a large health system to require certification for all pharmacists in direct patient care roles are detailed. SUMMARY: Major supply chain changes and rising payer expectations are reshaping pharmacy practice, resulting in expanded responsibilities for pharmacists and a heightened need for certification in specialized practice areas. In response, the pharmacy leadership team at UW Health, the integrated health system of the University of Wisconsin-Madison, used an iterative process and a "rolling" FAQ format to develop and implement a certification requirement. Key decisions during the process included decisions to accept only rigorous certifications (mainly those offered by the Board of Pharmacy Specialties), to provide institutional support for continuing education-based recertification, and to use an accepted definition of direct patient care in determining which pharmacists need to be certified. The team obtained the support of the UW Health human relations department by drafting a policy and rewriting all pharmacist position descriptions to incorporate the certification requirement. An all-pharmacist forum was held to build staff commitment. As a result of the requirement, 73 pharmacists were required to obtain certification by 2018 at a total cost to UW Health of $44,000; ongoing support of certification maintenance will cost an estimated $40,000 per year. CONCLUSION: Health systems can be successful in establishing uniform certification expectations for pharmacists in direct patient care roles, even across diverse practice settings, by aligning expectations with organizational goals.

New options and controversies in the management of chemotherapy-induced nausea and vomiting.

PURPOSE: An expanding array of options for prevention and treatment of chemotherapy-induced nausea and vomiting (CINV), including regimens containing olanzapine or recently approved neurokinin 1 (NK1) receptor antagonists, are reviewed. SUMMARY: Up to 80% of patients receiving chemotherapy have CINV. Current practice guidelines recommend that patients treated with highly emetogenic chemotherapy also receive a 3-drug antiemetic regimen initiated on the day of and continued for 3 days after chemotherapy administration, with the most commonly used 3-drug regimen consisting of an NK1 receptor antagonist, a 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist, and dexamethasone. Developments in the area of CINV management in recent years include the use of olanzapine in combination with a 5-HT3 antagonist and dexamethasone; Food and Drug Administration (FDA) approval of the NK1 receptor antagonist rolapitant, which provides a longer duration of effect than aprepitant; FDA approval of a combination product containing palonosetron and the NK1 receptor antagonist netupitant; and revisions of U.S. practice guidelines ending palonosetron's status as the preferred 5-HT3 antagonist for prevention of CINV associated with moderately or highly emetogenic chemotherapy. CONCLUSION: Newer therapeutic options for the management of CINV are equivalent to standard-of-care regimens in terms of efficacy and toxicity. While the NK1 receptor antagonist rolapitant and a product combining palonosetron and netupitant have potential advantages over standard therapy in terms of convenience or pharmacologic properties, their relatively high costs must be considered.