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2012 ISMP International Medication Safety Self Assessment® for Oncology Frequently Asked Questions

General

1. What if a specific self assessment item does not apply to the services provided in my organization/practice setting?
A few of the self assessment items offer the option of "Not Applicable." For these items "Not Applicable" can only be selected if your organization/practice setting does not provide the service. For example, if your organization/practice setting does not use radiolabeled chemotherapy/biotherapy drugs, you can answer "Not applicable" to item #92.
2. Our health system consists of three hospitals, which all share many of the same corporate functions (e.g., Pharmacy and Therapeutics [P&T] Committee, Risk Management, Information Technology, policies and procedures). Should we complete just one assessment for all three hospitals?
It is recommended that each hospital in a multihospital system complete the assessment individually and submit their information separately. The items in the assessment ask questions well beyond governance and policies and procedures that are in place. Each hospital will truly benefit if they complete the assessment individually and obtain their individual set of scores.

Demographics

1. Must I answer all of the questions in the demographics section?
All questions in the demographics section must be completed with the exception of question #23, which is optional.
2. Are there specific guidelines available for which choice to select for certain questions in the demographics section?
Assistance may be needed from your organization's/practice setting's administration for some of the demographic questions. Responses to these questions should correspond with responses your organization submits to licensing agencies, insurers, accrediting agencies, and other applications that may be required within your country.
3. What is meant by "describe your organization/practice setting" in question #3?
When describing your organization/practice setting, both inpatient and outpatient areas where chemotherapy and biotherapy is administered are being assessed. This includes inpatient nursing units, specialty areas (i.e., nuclear medicine, the operating room), outpatient clinics, ambulatory surgical centers, and private- or hospital-owned physician office practices. Select the category that best fits your organization/practice setting; for example, if your practice setting is a private physician office practice, you would indicate that you are an outpatient setting and indicate the number of chairs/beds in use and the percent (%) oncology.
4. What is meant by the number of doses administered per month in #9?
When determining how to answer this question, a dose is defined as one drug anytime it is prepared for administration. This information should be accessible through your pharmacy system or medication administration log.
5. My hospital is part of a collaborative that plans to aggregate the results of its hospital members. How do I obtain my code for question #23?
If you are part of a participating collaborative that plans to share its aggregate data internally, within the collaborative group, please contact ISMP or ISMP Canada to obtain a collaborative-specific code, which will then be entered into the box provided in question #23. If you are not part of a collaborative that will be aggregating its results, please leave this question blank.

SELF ASSESSMENT ITEMS

I. Patient Information

Core Characteristic #1

Item #8. What is meant by "prior to preparation"?
In this item we want to determine if chemotherapy/biotherapy agents are being prepared and sent to the infusion area before intravenous access is obtained and verified. Waiting to prepare the agents until after intravenous access is obtained and verified reduces the chance that the chemotherapy/biotherapy agents are not wasted or left in a location where they could be inadvertently administered to other patients.

Core Characteristic #2

Item #11. What is meant by "easily and electronically"?
Many organizations/practice settings are utilizing electronic documentation or have essential patient information in the computer system. Practitioners caring for these patients should be able to access this information easily, without going into multiple computer systems or various screens to get the information that is needed; i.e., they should be able to access this information from their work station with little difficulty.

II. Drug Information

Core Characteristic #3

Item #23a.
Answer N/A (Not Applicable) if your organization/practice setting does not have inpatient oncology services.
Item #23b.
Answer N/A (Not Applicable) if your organization/practice setting does not have outpatient oncology services.

Core Characteristic #4

Item #37.
Answer N/A (Not Applicable) if your organization/practice setting does not use investigational drugs.

III. Communication of Drug Orders and Other Drug Information

Core Characteristic #5

Item #40a.
Answer N/A (Not Applicable) if your organization/practice setting does not have inpatient oncology services.
Item #40b.
Answer N/A (Not Applicable) if your organization/practice setting does not have outpatient oncology services.

Core Characteristic #6

Item #45. What is meant by "ordered in detail" when prescribing the initial cycle of chemotherapy/biotherapy orders?
When chemotherapy/biotherapy is ordered, specific details need to be included. These are: generic name, brand name (if necessary), dose calculation, total dose, diluent, concentration, rate (infusion duration), drug sequence. If any of these items are commonly missing in chemotherapy/biotherapy orders, the organization cannot select E (fully implemented).
Item #45, 46, and 47. Do prescribers have to be oncologists or board certified in oncology to prescribe chemotherapy?
Prescribers need to have some formal training in order to write orders for chemotherapy/biotherapy for oncology and non-oncology indications. However, there are times when practitioners other than oncologists (e.g., urologists, neurologists) prescribe chemotherapy for oncology and non-oncology related conditions. As long as the prescriber has had some formal training in treating these specific conditions, then these items can be scored as being fully implemented. If general practitioners with no formal training in oncology are able to prescribe chemotherapy for oncology conditions in your organization/practice setting, then these items cannot be rated as being fully implemented (E).
Item #60. What is meant by a list of error-prone abbreviations being established for written and electronic orders?
The organization/practice setting has a defined list of error-prone abbreviations that are not used for drug order communication. This list is based on lists available from ISMP, ISMP Canada, or the Australian Commission on Safety and Quality in Health Care and is specifically designed to meet the needs of the organization/practice setting.
http://www.ismp.org/Tools/errorproneabbreviations.pdf
http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2006-04Abbr.pdf
http://www.health.vic.gov.au/qum/downloads/acsqhc_recommendations.pdf

Core Characteristic #7

Item #75.
Answer N/A (Not Applicable) if your organization/practice setting does not dispense oral chemotherapy/biotherapy drugs for patients to self-administer at home.

Core Characteristic #8

Item #77. When dispensing vinCRIStine, does the warning label have to be stated exactly as it is written in this item?
This is the World Health Organization (WHO) warning and it is the preferred warning.
Item #78 and 79.
Answer N/A (Not Applicable) if your organization/practice setting does not administer intrathecal medications.

IV. Drug Labeling, Packaging, and Nomenclature

Core Characteristic #9

Item #82.
Answer N/A (Not Applicable) if medications are not prepared for or administered by the intrathecal route in your organization/practice setting.
Item #83 a and b. Is there a standardized format that should be used for pharmacy-generated labels?
Many jurisdictions have requirements for information legally required on a prescription label (e.g., pharmacy name, address, phone number, patient name, drug name and manufacturer, dose, quantity dispensed, directions for use, date dispensed, etc); however they do not address how information is displayed on a hospital pharmacy label to optimize readability and understanding. ISMP has developed general labelling guidelines, available from: www.ismp.org/tools/guidelines/labelFormats/default.asp. Cancer Care Ontario has developed guidelines for labelling specific to oncology settings, Trudeau M, Green E, Cosby R et al. Evidence-Based Series #12-11, Patient Safety Issues: Key Components of Chemotherapy Labelling, available from: www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=50193

V. Drug Standardization, Storage, and Distribution

Core Characteristic #10

Item #91.
Answer N/A (Not Applicable) if your organization/practice setting does not use investigational drugs.
Item #92.
Answer N/A (Not Applicable) if your organization/practice setting does not use radiolabeled chemotherapy/biotherapy drugs.
Item #95. What is the definition of a commercially available standard base solution?
Errors have occurred in compounding base solutions from raw ingredients. It is recommended that commercially available base solutions be used; e.g., If 350 mL of sodium chloride 0.9% is needed, it is recommended that it be withdrawn from a 500 mL bag that was purchased from an accredited/certified vendor, not prepared on site, even if an automated compounder is available.
Item #96.
Answer N/A (Not Applicable) if your organization/practice setting uses only commercially available standard base solutions.

VI. Medication Device Acquisition, Use, and Monitoring

Core Characteristic #12

Item #111.
Answer N/A (Not Applicable) if your organization/practice setting does not use multichannel infusion pumps.
Item #112.
Answer N/A (Not Applicable) if your organization/practice setting does not use disposable controlled rate devices (e.g., elastomeric).

VII. Environmental Factors, Workflow, and Staffing Patterns

Core Characteristic #13

Item #118a.
Answer N/A (Not Applicable) if your organization/practice setting does not have inpatient oncology services.
Item #118b.
Answer N/A (Not Applicable) if your organization/practice setting does not have outpatient oncology services.
Item #130.
Answer N/A (Not Applicable) if your organization/practice setting does not use closed system transfer devices.

VIII. Staff Competency and Education

Core Characteristic #14

Item #141.
Answer N/A (Not Applicable) if your organization/practice setting does not provide oncology services requiring patient transfer between departments.

X. Quality Processes and Risk Management

Core Characteristic #17

Item #158. Does our organization/practice setting have to employ one full-time employee to review and analyze medication errors?
This does not need to be a designated position for a full-time employee; it just means that it has to be part of someone's regular job responsibilities whether they are full-time or part-time. They can have other primary responsibilities, but this should be included as a specific function in their job description.

Core Characteristic #18

Item #167. What is meant by "verification"?
This does not mean that the pharmacist or nurse needs to weigh the patient or measure the patient's height again. It means that if there is ANY question that these measurements are not accurate (i.e., have been entered or documented incorrectly) that a reasonableness check or visual check is then done. We have received error reports where the height was entered as the weight and the weight was entered as the height, resulting in an overdose.