In real estate, the saying goes, success relies on location, location, location. But in oncology nursing, the key, when it comes to patient safety, is education, education, education. It’s education in terms of staying on top of an ever-expanding universe of treatments. It’s education that helps oncology nurses master processes that ensure a safe environment for patients. And finally, it’s education of patients themselves.

In the past few decades, the number of available chemotherapy agents has exploded, says Carlton Brown, RN, PhD, AOCN, president of the Oncology Nursing Society. “Each of these drugs has its own individual symptoms, and can have their own precautions about the way they’re administered,” he says. Consequently, oncology nurses not only need hands-on abilities, but ongoing, specialized education, preferably where skills and knowledge are periodically verified, Brown says.

A nurse’s expertise is the most important factor in oncology patient safety, says Martha Polovich, RN, PhD, AOCN, associate director of clinical practice at the Duke Oncology Network in Durham, N.C. “People who are outside the specialty don’t really get it — it’s always something new, and it’s always being aware of that fact,” she says. “When you work in an outpatient setting and you have a lot of patients coming in, they could have one of 200 different diagnoses, and each one has a slightly different slant to how it’s managed and what’s important for the patient.”

While it’s up to individual hospitals or clinics to ensure nursing expertise, ONS provides education and processes to support those efforts, says Brown, an assistant professor in the School of Nursing at the University of Delaware in Newark. Key ONS resources include online classes, local sponsored education, printed materials and Web resources, he says. Nurses also can tap pharmacists, clinical staff from drug companies, and nursing and oncology journals to help stay current.

A cardinal rule for oncology nurses, Polovich says, is first do no harm. “Even when we do it right there are side effects … so it’s extremely important to do it right,” she says. “There’s a risk-benefit ratio for patients. You want to minimize that risk and maximize that benefit.”

Safety in Processes
In a 2009 study, published in the Journal of Clinical Oncology, of medication mistakes in cancer outpatients, error rates were striking. Among 1,262 adult patient visits involving nearly 11,000 medications, errors occurred 7.1% of the time, the study found. For pediatric patients, in 117 visits involving more than 900 medications, errors happened 18.8% of the time. Mistakes were most often because of errors in administration, commonly related to confusion over original orders versus later dose adjustments, the researchers found.

Establishing and following safety processes, such as double-checking on doses, can help practitioners avoid medication errors. “No one sets out saying, ‘I think I’ll make a chemotherapy error today.’ But everyone’s human,” Polovich says.
Focusing on safety is an ongoing task, she adds. Sometimes on site visits she finds that nurses are using only the patient’s name, and not a second identifier, for verification before treatment.

“Small clinics may have only three chairs, and I’ve been there when they have two patients with the same name, or two people getting the same treatment at the same time,” she says. “How easy is that to make a mistake? These are high-risk medications, and you want to have as many stops in there as possible to ensure this is the right patient, right drug, right dose.”

A joint initiative of ONS and the American Society of Clinical Oncology is aimed at ensuring “right patient, right drug, right dose” — and more — for chemotherapy. The ASCO/ONS Chemotherapy Administration Safety Standards, issued in 2009, look at multiple aspects of patient safety in an oncology outpatient setting, including how medicines should be ordered, prepared and administered; how patients should be monitored; and key points on patient education and consent, says Polovich, who helped work on the recommendations. In all, 31 standards were part of the final document, which addresses adult cancer care.

Brown hopes nurses will embrace the standards and be proactive in implementing them at their workplaces. But implementation also will require commitment from hospitals and clinics.

For instance, the standards say qualified people should administer chemotherapy and that organizations should demonstrate how they will ensure this. “You have to have a program, a process in place for verifying it happens,” says Polovich, who says the guidelines are undergoing minor revisions. She also expects them to be extended to inpatient settings.

Watching for Toxicities

Monitoring for chemotherapy toxicities is complicated. As oncology RNs know, skin redness or rash resulting from one type of chemotherapy may mean it should be stopped or revised; for another it can simply mean the treatment is working. Nurses not only need to know the difference, but educate their patients about what such symptoms mean, says Brown, editor of a textbook on oncology symptom management and author of a book for patients on cancer symptoms.

Patients on oral medications might decide on their own to stop taking them. They also might fail to take their medicines exactly as prescribed. ONS is looking for better ways to remind patients or otherwise help them comply with treatment, Brown says.

“This is really important in the treatment of cancer,” Polovich, co-editor of ONS’ Chemotherapy and Biotherapy Guidelines and Recommendations for Practice, says. “If patients have disease progression and they’re on an oral agent, is it because the drug didn’t work or because they didn’t take it the way they are supposed to? You might change therapy on the premise that they took the therapy correctly, which may not be the case.”

Patients should be partners in their treatment from the outset: Polovich notes that one of the ASCO/ONS safety standards involves establishing a treatment plan and ensuring that patients understand it. “At a minimum [they should know] what drugs, how many cycles and what is the goal,” she says, adding that patients who understand their therapy might also help prevent errors in its administration.

Also, nurses should remember that patients don’t always absorb what they are told at first. “It’s important to communicate again periodically and to give patients something in writing they can refer to when their brain recovers from hearing bad news.”

Oncology nurses also must be experts in recognizing other circumstances that impact patient health. For instance, nausea from treatment can exacerbate nutritional deficiencies. And chemotherapy could put frail patients, or those with ambulation problems, at greater risk of falls. “Patients who are dehydrated or have low blood cell counts or are not getting proper oxygen are at risk,” Brown says. “A couple of medications that we give cause peripheral neuropathy, a numbness of fingers and toes … that may also cause them to be at risk of falls.”

Radiation settings pose their own nursing challenges. Practices might have just one nurse, who may or may not see patients every time they come in, giving them less opportunity to report side effects, Brown says. “It’s important for the nurse to understand the symptoms, and especially those outliers, and say, ‘Whoa, that’s not normal; maybe we should have the radiation oncologist look at that.’”

Polovich says it’s imperative for oncology nurses to know the multimodal treatments their patients are receiving as they assess them for complications. Nurses also must be ready to contact other care providers when needed. “Multiple sites of care bring more problems,” she says. “Communication is key.”

The Long View

Knowing how best to monitor patients during treatment has implications for their long-term health. For instance, Polovich says, long-term cardiac effects are more likely to occur in people who get a higher total lifetime dose of certain drugs.

“Someone has to keep track,” she says. “Someone has to make sure baseline evaluation of that person’s cardiac functioning occurs before treatment possibly makes that worse.” Sometimes it’s as simple as nurses pointing out they haven’t seen a needed scan recently, she adds.

Education of patients is also essential as they leave treatment, so they know what symptoms to watch for and what monitoring they need. Treatment summaries help both primary care providers and patients understand what should be done for their health in the future.

Expert oncology care has had a sweeping impact in recent years, Brown notes. “We have an estimated 11 million survivors in the United States who have been treated for, and who are surviving, their cancer.”