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Review

Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems

Donald K. Baker  1 , James M. Hoffman  1 , Gregory A. Hale  1 , Sheri L. Spunt  1 , Donald Sanderlin  1 , John H. Rodman  1 , Jerry L. Shenep  1
Kerm Henriksen, James B Battles, Margaret A Keyes, Mary L Grady
, editors.
In: Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug.
Advances in Patient Safety.
Affiliations
Review

Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems

Donald K. Baker et al.

Excerpt

Objective: The objective of this project was to evaluate the risks associated with converting a paper-based pediatric chemotherapy ordering process to a fully electronic system. Methods: Formal process redesign and systems analysis, primarily through Failure Mode and Effects Analysis (FMEA), was used to evaluate the current, paper-based chemotherapy medications process. A commercial software system designed to accomplish computerized provider order entry (CPOE), safety checks, pharmacy dispensing, and medication administration documentation were examined to determine whether these integrated applications are as safe as a paper process with multiple redundant checks. Results: Formal process redesign and system analysis methods uncovered important potential failure points within the integration points of the electronic system. Conclusion: Prospective, institution-specific process redesign and system analysis is a valuable tool for determining the safety and feasibility of converting complex medication ordering processes from paper to electronic systems. Commercially available CPOE systems may not be immediately capable of safely executing complex chemotherapy regimens.

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