Bahan 4

JBI Database of Systematic Reviews & Implementation Reports 2015;13(10) 316 - 334
Documentation of chemotherapy administration by nursing staff in

inpatient and outpatient oncology/hematology settings: a best
practice implementation project
1
Allison Turner
2
Matthew Stephenson
1. Chemotherapy Clinical Development Nurse, Cancer, Ambulatory and Community Health

Service, Canberra Hospital and Health Services. Australia
2. The Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, Australia
Primary contact
Allison Turner
Allison.Turner@act.gov.au
Key dates
Commencement date: July 2014
Expected Completion date: December 2014
Executive summary
Background
Documentation of chemotherapy administration by nursing staff is undertaken in a written and

electronic form at the Canberra Hospital and has been identified as requiring improvement in
both inpatient and outpatient settings. Safe prescribing, dispensing, administration and
documentation are essential to patient safety, outcomes and quality of care, and to staff
safety. Due to the limited available research and evidence on this topic, recommended safety
standards for the safe administration of chemotherapy formed the framework for audit criteria
and documentation requirements.
Objectives
The aim of this evidence implementation project was to improve documentation of

chemotherapy administration by nursing staff in inpatient and outpatient oncology/hematology
units, thereby improving patient care and safety, as well as meeting the legal and educational
responsibilities of the nursing staff.
doi: 10.11124/jbisrir-2015-2157 Page 316

Methods
This evidence implementation project used the JBI Practical Application of Clinical Evidence
System and Getting Research into Practice audit and feedback tool. A baseline audit was
conducted to assess current practice and identify areas requiring improvement, followed by
reflection on results and design, and implementation of strategies for documentation
improvement. Lastly, a follow-up audit was conducted to assess compliance and practice
improvement.
Results
The baseline audit results highlighted areas of good current practice, areas requiring
improvement and barriers to data collection and practice improvement. Strategies based on
raising awareness of best practice guidelines, education and useful tools were developed and
implemented. It was evident that the electronic documentation prompts used in the outpatient
setting, compared to paper-based documentation in the inpatient setting, contributed to better
compliance to documentation guidelines. The follow-up audit demonstrated improved
practices across both the inpatient and outpatient settings.
Conclusions
The aim of improving documentation after chemotherapy administration was achieved, yet
there is still room for further improvement. Education will continue through training courses,
communication at meetings and utilization of the tools developed. Future auditing is planned
to ensure sustainability.
Keywords
audit; best practice; chemotherapy; documentation; evidence implementation; inpatient;

outpatient
Background
Chemotherapy and targeted therapies are used for the treatment of malignant and non-malignant
diseases, and may be used with curative or palliative intent. Safe prescribing, dispensing,
administration and documentation are essential to patient safety, outcomes and quality of care, and to
1,2
staff safety. Patients being treated for a cancer diagnosis require holistic, multifactorial care,
3
involving on-going physical and psychological assessment and care.
Timely, relevant and detailed documentation is vital from both medical and legal perspectives, and is
4
an essential nursing responsibility. Documentation enables communication of information relevant to
the patient’s needs, condition, care and treatment, and is useful when investigating incidents
4
concerning chemotherapy administration.
Documentation may be completed in a written and electronic form and has been seen to require
4
improvement in both inpatient and outpatient settings. During routine clinical record reviews and
investigation of chemotherapy related incidents at the Canberra Hospital by the author, it was found
that some documentation lacked important information regarding chemotherapy protocol, blood
results, intravenous access and patency, physical and psychosocial assessment of the patient,
doi: 10.11124/jbisrir-2015-2157 Page 317

administration of prescribed medications, post-administration requirements and care, and safe

handling.
This quality improvement project targeted two oncology/hematology units at the Canberra Hospital –
one inpatient unit and one outpatient unit. Ward 14B is a 44-bed inpatient ward for any patient with a
cancer diagnosis, with an average of five to ten patients a day requiring chemotherapy administration.
5
On Ward 14B, chemotherapy is prescribed using the CHARM™ electronic system , but with paper-
based documentation of the prescription and a paper-based clinical record. CHARM™ is an oncology
information management solution for cancer care clinical coordination and management enabling
electronic prescribing of chemotherapy protocols by hematology and oncology consultants and
advanced trainees. The system is backed by appropriate protocols located on eviQ (NSW Cancer
6 7,8
Institute) , and recent journal articles based on evidence-based practice and clinical trials. Level 4 of
the Canberra Region Cancer Centre is an outpatient oncology/hematology unit that currently treats
approximately 60 patients a day, of which 90% receive chemotherapy. The chemotherapy prescription
and all clinical (medical and nursing) documentation are done electronically on CHARM™, with a
paper-based copy of the prescription signed and scanned onto the electronic clinical record.
Documentation in the inpatient setting is individual staff member dependent, with an absence of
guidelines available for paper-based documentation at the baseline audit.
In the outpatient setting, all documentation is completed electronically on the CHARM™ system,
where documentation guidelines according to best practice are partly supported by the drop-down
“Notes” box containing the following prompts:
 Cycle/Day
 Bloods
 Patient assessment
 IVC inserted
 CVAD
 Treatment given
 Issues/Complications
 Appointments confirmed
 Discharge medications provided.
Despite the different mechanisms for documentation in the two settings, the information should be the
same.
There is little research and evidence available on this topic; however a number of nursing groups and
experts support safety standards for the safe administration of chemotherapy, including the Clinical
1
Oncological Society of Australia (COSA) and the American Society of Clinical Oncology/Oncology
2
Nursing Society (ASCO/ONS). The recommended standards form a framework for documentation
requirements.
Auditing took place across both inpatient and outpatient oncology/hematology units of the Canberra
Hospital, using document review. The aim was to audit chemotherapy documentation on 100
occasions of service- 50 inpatients and 50 outpatients. The stakeholders of this project were identified
doi: 10.11124/jbisrir-2015-2157 Page 318

as the Director of Nursing and the Assistant Director of Nursing of Cancer, Ambulatory and
Community Health Support (CACHS), and the Clinical Nurse Consultants of the inpatient and
outpatient settings. The Project Leader performed all audits, collation, education and practice change,
with support from managerial stakeholders.
Aims and objectives

The aim of this evidence implementation project was to improve documentation of chemotherapy
administration by nursing staff in inpatient and outpatient oncology/hematology units, thereby
improving patient care and safety, as well as meeting the legal and educational responsibilities of the
nursing staff.
The specific objectives of the project were to:
 Identify current practices in inpatient and outpatient oncology/hematology settings
 Reflect on baseline audit results and design strategies to implement best practice
underpinned by expert standards and recommendations
 Devise an education program for chemotherapy nurses to address recommended

documentation guidelines and areas of non-compliance
 Undertake a follow-up audit to assess the extent and nature of increased compliance with
recommended best practice
 Identify strategies to sustain and enhance improved chemotherapy documentation by nursing

staff.
Methods
This evidence implementation project used the JBI Practical Application of Clinical Evidence System
(PACES) and Getting Research into Practice (GRiP) audit and feedback tool. The PACES and GRiP
framework for promoting evidence-based health care involves three phases of activity:
1 Establishing a team for the project and undertaking a baseline audit based on criteria
informed by the evidence.
2 Reflecting on the results of the baseline audit, and designing and implementing strategies to
address non-compliance found in the baseline audit informed by the JBI GRiP framework.
3 Conducting a follow-up audit to assess the outcomes of the interventions implemented to

improve practice, and identify future practice issues to be addressed in subsequent audits.
Audit criteria were developed based on a JBI Evidence Summary on chemotherapy documentation by
nursing staff, including the best available evidence identified from a structured search of the literature
9
and selected evidence-based health care databases. Due to a lack of specific research evidence on
chemotherapy documentation, audit criteria were formulated according to expert guidelines for
1
chemotherapy administration from the Clinical Oncological Society of Australia (COSA) and the
2
American Society of Clinical Oncology/Oncology Nursing Society (ASCO/ONS).
Low level ethics approval was sought due to the need to access clinical records; however the ACT
Health Human Research Ethics Committee – Low Risk Sub-Committee deemed this work to be a
quality assurance project, thereby not requiring ethics approval.
doi: 10.11124/jbisrir-2015-2157 Page 319

Data was collected from patients’ paper clinical notes in the inpatient setting, and by accessing
patients’ electronic clinical records in the outpatient setting.
The audit criteria were pilot tested prior to commencement of the baseline audit to ensure their
applicability to the inpatient and outpatient settings.
Phase 1: Stakeholder engagement (or team establishment) and baseline audit
The project leader and first author of this article is the Chemotherapy Clinical Development Nurse at
the Canberra Hospital, and undertook this project in order to complete a Joanna Briggs Institute
Evidence Based Clinical Fellowship Program. All data collection and data analysis were completed by
the project leader. Support was provided by managerial stakeholders of the Canberra Hospital’s
Division of Cancer, Ambulatory and Community Health Support:
Gaynor Stevenson, Director of Nursing
Denise Breust, Assistant Director of Nursing
Wendy Spencer, Clinical Nurse Consultant, Outpatient Oncology/Immunology
Kathlene Robson, Clinical Nurse Consultant, Outpatient Hematology
Sue Langdon, Clinical Nurse Consultant, Inpatient Hematology/Oncology
David Larkin PhD, Research Officer
All registered nursing staff who administer chemotherapy were deemed to be stakeholders in this
project. The baseline audit was conducted during September 2014. Table 1 below shows the
evidence informed audit criteria used in the project (baseline and follow-up audit) together with a
description of the sample and approach to measuring compliance with best practice for each audit
criterion. The audit criteria used in the inpatient and the outpatient settings were identical. Audit
criteria were assessed with Yes, No and Not Applicable (N/A) responses.
Table 1: Audit criteria
Audit criterion Sample Method used to measure % compliance

with best practice
1. It is documented that 50 occasions of Electronic medication chart checked for
the presence or chemotherapy documentation of allergies
absence of medication administration in each
Allergies could be documented by nursing staff
allergies has been setting
if not completed by prescribing doctor
checked
2. Assessment of access 50 occasions of Type of access device and proof of patency
device required for chemotherapy documented
administration is administration in each
documented setting
3. Pre-medication/pre- 50 occasions of Could be documented either in the clinical
hydration is chemotherapy notes or signed for on the CHARM™ chart
documented administration in each
setting
4. Chemotherapy 50 occasions of Could be documented either in the clinical
administration chemotherapy notes or signed for on the CHARM™ chart
according to the administration in each
protocol is documented setting
doi: 10.11124/jbisrir-2015-2157 Page 320


with best practice
5. Post-medication/post- 50 occasions of Could be documented either in the clinical
hydration is chemotherapy notes or signed for on the CHARM™ chart
setting
6. Treatment related 50 occasions of Toxicities/side-effects/reactions (or lack of
toxicities/side–effects chemotherapy same) documented in clinical notes
are documented administration in each
setting
7. Self-care instructions 50 occasions of Any instructions (e.g. taking anti nausea
for patient post chemotherapy medication, attending mouth care)
administration are administration in each documented in clinical notes
documented setting
8. Duration of cytotoxic 50 occasions of Documentation of how long cytotoxic
precautions is chemotherapy precautions are to be observed
setting
9. Follow-up 50 occasions of When and where next cycle or appointment is
appointment/next cycle chemotherapy booked for
is documented administration in each
setting
10. Referrals to services 50 occasions of Referral made to any multidisciplinary service
are documented chemotherapy documented in clinical record
administration in each
setting
11. Chemotherapy nurses 10 Registered Nurses Verbal questioning of staff
have received in the inpatient setting
education regarding and 40 Registered
appropriate Nurses in the
documentation outpatient setting
applicable to
chemotherapy
administration
12. The patient’s diagnosis 50 occasions of Automatically documented as part of
is documented chemotherapy prescription on CHARM™ chart
setting
13. It is documented that 50 occasions of Documented acknowledgement in the clinical
recent blood tests have chemotherapy notes that blood tests had been checked
been checked and administration in each
action taken as setting
required
14. Physical assessment of 50 occasions of Specific issues or “nil known complaints”
the patient is chemotherapy documented in clinical notes
setting
15. Psychosocial 50 occasions of Specific issues or “nil known complaints”
assessment of the chemotherapy documented in clinical notes
patient is documented administration in each
setting
doi: 10.11124/jbisrir-2015-2157 Page 321


with best practice
16. Patient education is 50 occasions of Documentation in the clinical notes confirming
documented chemotherapy that patient education had been provided
setting
17. Informed consent or 50 occasions of Documentation of patient’s verbal consent, or
approval to proceed is chemotherapy doctor’s approval to proceed
setting
18. Verification of the 50 occasions of Each page of CHARM™ chart (prescription)
treatment plan chemotherapy signed by the qualified nurse who will
(protocol), administration in each administer the chemotherapy and the checker
chemotherapy order setting with CCC (CHARM™ Chart Check)
and patient
identification by two
qualified staff is
documented
Phase 2: Design and implementation of strategies to improve practice (GRiP)
At the inception of this project, chemotherapy administration documentation was placed on agendas
of ward/area meetings, Nursing Governance meetings and Clinical Development Nurse meetings
within the cancer service, and as an integral part of chemotherapy training. These forums enabled
regular communication, information and result sharing, as well as identification of barriers to effective
documentation after chemotherapy administration. Best practice guidelines were identified and used
both as audit criteria and documentation topics. Using PACES, the baseline audit identified areas of
good and excellent practice and areas of reduced or no compliance. Education was the primary
strategy to improve compliance, with a number of tools and communication techniques required to
target staff across the two areas.
Phase 3: Follow-up audit post implementation of change strategy
The objective of the follow-up audit was to measure improvement of documentation, in line with best
practice guidelines. The follow-up audit was conducted in the same manner as the baseline audit,
using the same audit criteria and sample sizes.
doi: 10.11124/jbisrir-2015-2157 Page 322

Results
Phase 1: Baseline audit
The results of the baseline audits are shown in Figure 1 (a) for the inpatient setting, and 1 (b) for the
outpatient setting.
Figure 1 (a): Compliance with best practice audit criteria in baseline audit (%) in the inpatient
hematology/oncology setting
Figure 1 (b): Compliance with best practice audit criteria in baseline audit (%) in the outpatient
hematology/oncology setting
doi: 10.11124/jbisrir-2015-2157 Page 323

Criterion 1 (it is documented that the presence or absence of medication allergies has been checked)
achieved results of only 44% compliance in the inpatient setting and 58% in the outpatient setting.
While the prescribing doctor should document the presence or absence of medication allergies on the
CHARM™ Chart prescription, it is the administering nurse’s responsibility to check for allergies and
document them accordingly. This is an area that must be improved and sustained.
Criterion 2 (assessment of access device required for administration is documented) achieved 100%
compliance across both areas as it is such a vital component of chemotherapy administration.
Documentation of premedication/pre-hydration (criterion 3) showed 83% compliance in the inpatient

setting and 98% in the outpatient setting, with documentation of chemotherapy administration
according to protocol (criterion 4) showing 88% compliance in the inpatient setting and 98% in the
outpatient setting.
Post medication/post hydration (criterion 5) was only documented in the inpatient setting on 42% of
occasions, but may have been overlooked due to the orders being prescribed on the CHARM™ chart.
The outpatient compliance was 95%.
Toxicities/side effects/reactions (criterion 6) were only documented in the inpatient setting on 44% of
occasions, and on 50% of occasions in the outpatient setting, primarily when they had occurred rather
than when they were absent.
Self-care instruction documentation (criterion 7) showed poor compliance in the inpatient setting, but
may be explained by the fact that instructions are documented on a chart that does not form part of
the patient’s clinical record. Documentation of self-care instructions in the outpatient setting showed
compliance of only 16% on occasions of service, but should be noted that self-care instructions are
explained at the initial education session and verbal reminders are given at each visit.
Duration of cytotoxic precautions is documented (criterion 8) also achieved poor results of 18% in the
inpatient setting, where observance of cytotoxic precautions was documented in the clinical record,
but the duration of precautions was only documented on a sign that did not form part of the clinical
record. Cytotoxic precautions in the outpatient setting were not documented at all, thereby achieving a
0% result. However, cytotoxic precautions are addressed in the pre-treatment education session.
Follow-up appointments and treatment cycles (criterion 9) were only documented in the inpatient
setting on 18% of occasions, which is understandable considering patients receiving chemotherapy in
an inpatient setting tend to be more unwell, endure longer protocols and take longer to recover from
treatment, therefore follow-up appointments are more difficult to book. Compliance in the outpatient
setting was 98%.
Referrals to other services (criterion 10) were documented in the inpatient setting on 40% of
occasions, but are often already in place in the inpatient setting. Referrals to services from the
outpatient setting (such as Community Nursing, Cancer Nurse Care coordinators, allied health and
support networks) were made on 88% of occasions of service.
Criterion 11 (chemotherapy nurses have received education regarding appropriate documentation

applicable to chemotherapy administration) also achieved 100% compliance in that, on questioning,
staff had received some form of education, but not necessarily according to all the best practice
guidelines.
doi: 10.11124/jbisrir-2015-2157 Page 324

Criterion 12 (the patient’s diagnosis is documented) achieved 100% compliance across both areas as
it forms part of the CHARM™ Chart prescription.
Blood results checking (criterion 13) in the inpatient setting was only documented on 52% of
occasions, but this may be due to subsequent days of a chemotherapy protocol, where blood tests
may not have been repeated or treatment would proceed regardless of results. Outpatient compliance
was 79%.
In the inpatient setting, physical assessment of patients (criterion 14) was only documented on 40% of
occasions, with psychosocial assessment (criterion 15) only mentioned in 10% of notes. It must be
noted that as inpatients, these assessments are regularly attended and documented by medical staff
and ward nurses, thereby forming part of the patient’s clinical record. In the outpatient setting,
physical assessment was documented on 78% of occasions, with psychosocial assessment
documented on 50% of occasions.
Education of the patient (criterion 16) pertained to education being provided on that occasion of
service, most often referring to the formal education session given prior to commencing treatment,
which showed 74% compliance in the inpatient setting and 86% in the outpatient setting. There were
74 occasions deemed not applicable as they were subsequent days or cycles of treatment.
Criterion 17 (informed consent or approval to proceed is documented) achieved poor results of 10% in
the inpatient setting and 0% in the outpatient setting, as written consent for chemotherapy
administration is not sought or given in the Division of Cancer, Ambulatory and Community Health
Support. Approval to proceed from the patient or medical officer will occasionally be documented by
the chemotherapy nurse in the inpatient setting, while a patient arriving for a treatment appointment is
deemed to be consenting in the outpatient setting.
The baseline audit showed that chemotherapy nurses in the inpatient setting only documented
verification of the treatment plan (protocol), chemotherapy order and patient identification by two
qualified staff (criterion 18), seen in the signing by both staff with a CCC (CHARM™ Chart Check) on
the paper based prescription, 70% of the time. In the outpatient setting, criterion 18 showed excellent
compliance, as seen in the CCC (CHARM™ Chart Check), at 94% of occasions of service.
The baseline results clearly showed areas of good compliance across both settings, and areas where
improvement could be made. Explanations of other services and tools in place in the inpatient setting
justified the results of some criteria.
Phase 2: Strategies for Getting Research into Practice (GRiP)
Careful consideration was given to developing strategies for GRiP, as they had to be introduced
across the outpatient setting and the inpatient setting where staff worked rotating shifts.
Communication was essential throughout the six months of this project, starting with areas requiring
improvement according to best practice guidelines being acknowledged and accepted, what forms of
communication, education and changes would be beneficial, and how best to feedback information
and results.
The decision was made to ensure chemotherapy documentation was a standing item on all meeting
agendas, including ward/area meetings, chemotherapy staff meetings, Clinical Development Nurse
meetings and Nursing Governance meetings (the latter allowing feedback, results and information to
managers).
doi: 10.11124/jbisrir-2015-2157 Page 325

“Documentation guidelines around chemotherapy administration” (Appendix I) was developed

according to best practice guidelines and made available to staff by email, and laminated and
displayed at all work stations in the inpatient and outpatient settings. Staff in the outpatient setting
also had the added advantage of electronic documentation and the drop down “Notes” box on
CHARM™ which addresses eight of the criteria. Baseline audit results were also distributed to staff
via email and presented at meetings. Chemotherapy documentation tags (Appendix II) for lanyards
and ID tags were developed and laminated, then distributed to all nursing staff who administer
chemotherapy, enabling guidelines to be available to staff at all times. The guidelines were also
included in the Antineoplastic Drug Administration Course that was facilitated by the author in the
Division of Cancer, Ambulatory and Community Health Support.
Table 2 shows the key barriers to compliance with best practice that were identified, along with the
strategies developed to overcome these barriers. The resources that were required for the
implementation strategies are detailed as well as the outcomes achieved.
Table 2: GRiP matrix
Barrier Strategy Resources Outcomes

Lack of staff  Education sessions  Documentation Staff have better
knowledge guidelines around understanding of
regarding guidelines  Development of chemotherapy specific guidelines
for documentation documentation education tool for documentation
guidelines developed (see after chemotherapy
 Agenda item for ward Appendix I) administration
meetings, Nursing  Laminated and placed
Governance at each work station
meetings,
chemotherapy  Minuted at each
meetings and Clinical meeting
Development Nurse
meetings  Guidelines emailed to
all staff (Registered
 Inclusion in Nurses) who administer
Antineoplastic Drug chemotherapy
Administration
Course
Available time for  Ensure the  Chemotherapy More thorough
thorough guidelines are readily Documentation tag documentation and
documentation available for staff produced for inclusion increased efficiency
allowing rapid on staff members’ with the guidelines
consultation lanyard ID (Appendix II) readily available
 Utilization of drop down
box in Charm™
Encounters (clinical
notes) in outpatient
setting
doi: 10.11124/jbisrir-2015-2157 Page 326

Phase 3: Follow-up audit(s)
After six to eight weeks of implementing strategies of GRiP, follow-up audits were conducted using
the same audit criteria and sample size of 100 occasions of service – 50 in the inpatient setting and
50 in the outpatient setting. The follow-up audit results, compared to the baseline audit results, for the
inpatient setting are shown in Figure 2 (a) and those for the outpatient setting are shown in Figure 2
(b).
Figure 2 (a): Compliance with best practice audit criteria in follow-up audit compared to
baseline audit (%) in the Inpatient Hematology/Oncology setting
doi: 10.11124/jbisrir-2015-2157 Page 327

Figure 2 (b): Compliance with best practice audit criteria in follow-up audit compared to
baseline audit (%) in the Outpatient Hematology/Oncology setting
In Figures 2 (a) and 2 (b), criteria which showed a high compliance rate in the baseline audit
remained largely unchanged in the follow-up audit across both settings.
As can be seen from Figure 1 (b), criteria 2, 3, 4, 5, 9, 13 and 14 rated between 78% and 100% in
documentation compliance in the outpatient setting, most likely due to the availability of drop down
notes on the electronic CHARM™ system.
doi: 10.11124/jbisrir-2015-2157 Page 328

There was obvious improvement in varying degrees across many of the remaining criteria. However,
poorer compliance to four criteria (criteria 1, 2, 7 and 10) in the inpatient setting and five (criteria 2, 5,
7, 13 and 16) in the outpatient setting were demonstrated in the follow-up audit.
Discussion
The aim of this implementation project was to improve nursing documentation of chemotherapy
administration in the inpatient and outpatient settings of the Canberra Hospital. In the inpatient setting,
the follow-up audit showed improvements in 12 of the 18 criteria, with another two criteria remaining
unchanged at 100%. In the outpatient setting, there were improvements in 10 of the 18 criteria, with
another three criteria remaining unchanged at 98-100%. The prompts available in the CHARM™
electronic documentation used in the outpatient setting contributed to better evidence based
documentation. Feedback and results from both audits to nursing staff occurred at ward meetings and
via email. Results were presented to managers at education meetings and nursing governance
meetings.
In both settings, the distribution of guidelines through posters, email, prompt cards for lanyards and
inclusion of the guidelines in the chemotherapy training course raised awareness of recommended
best practice for documentation around chemotherapy administration. In the inpatient setting, there
was marked improvement in the documentation of post-medication and post-hydration (criterion 5),
toxicities/side effects/reactions (criterion 6), follow-up appointments (criterion 9), blood results
checking (criterion 13), physical assessment (criterion 14) and patient education (criterion 16). In the
outpatient setting, there was noted improvement in the documentation of toxicities/side
effects/reactions (criterion 6) and physical assessment (criterion 14), along with consistent
compliance in many of the other criteria.
The challenges of this project revolved around concentrating on two settings, the need for 18 criteria
to address recommended guidelines and changing of staff’s documentation habits. The feedback from
staff on the strategies implemented through GRiP was very positive, and further improvement in
practice is expected.
The wording of the criteria dictated the actual data collected, and different results would have been
achieved if they had been worded slightly differently. For example, the duration of cytotoxic
precautions documented in the inpatient setting resulted in the poor compliance of 8% in the follow-up
audit, whereas there would have been 90-100% compliance had it just said “documentation of the
need for cytotoxic precautions”.
The results of documentation of referrals (criterion 10) in the inpatient setting did not allow
acknowledgement of referrals by clinicians other than staff administering chemotherapy, so removal
of this criteria for future auditing in the inpatient setting would be considered.
Criterion 11 (chemotherapy nurses have received education regarding appropriate documentation

applicable to chemotherapy administration) would need to be more specifically written in order to gain
more accurate data. All nurses have had education about documentation, but it would be useful to
know if they were aware of the specific guidelines recommended as best practice for chemotherapy
administration.
While criterion 18 (verification of the treatment plan [protocol], chemotherapy order and patient
identification by two qualified staff is documented) improved from 70% to 78% with each page of the
doi: 10.11124/jbisrir-2015-2157 Page 329

CHARM™ chart being signed and dated in the inpatient setting, it is suspected that the task was in
fact performed 100% of the time. Continued education will be required to ensure staff sign each page
of the order.
The relatively poor performance for documentation of presence or absence of medication allergies
(criterion 1) will require education of the doctors who prescribe chemotherapy, as well as further
education to nursing staff on their responsibility to check and document the presence or absence of
allergies on the CHARM™ chart.
The main area of non-compliance, and deemed to be impossible to rectify, is the gaining of consent
for administration of chemotherapy. The Canberra Hospital does not require written consent for the
administration of chemotherapy for either inpatients or outpatients. Consequently, improved results for
this criteria are not expected.
In order to continue to improve and sustain thorough documentation around chemotherapy

administration, the plan is to continue to distribute the tools developed and include education in
area/ward meetings and chemotherapy administration courses. The CHARM™ system is currently
under review at the Canberra Hospital, and the possibility of expanding the drop down “Notes” box to
include more criteria based on the guidelines is being explored. A second follow-up audit is planned in
six to 12 months to maintain and sustain practice change.
Conclusion
Documentation is an essential nursing responsibility from medical, legal and information-sharing
perspectives. Thorough documentation after administration of chemotherapy is essential to patient
safety, outcomes, quality of care and staff safety. Due to the limited available research and evidence
on this topic, recommended safety standards for the safe administration of chemotherapy formed the
framework for the audit criteria and documentation requirements. Different documentation techniques
between the inpatient setting and the outpatient setting made standardized education and tools
necessary, in order to cover all areas of practice based on the best practice guidelines, and not only
the areas of poor compliance. The inpatient setting still uses paper based documentation, while the
outpatient setting is fully electronic and includes the drop-down “Notes” box on CHARM™, which
addresses eight of the recommended criteria, with the possibility of expansion being explored. There
is also the possibility of the remaining criteria being added in the future.
In conclusion, the aim of improving documentation after chemotherapy administration was certainly
achieved, yet there is still room for further improvement. Education will continue through training
courses, communication at meetings and utilization of the tools developed. It is clear that this project
promoted understanding and raised awareness of the recommended guidelines to all staff
administering chemotherapy in both inpatient and outpatient settings.
Conflict of interest
The authors declare that there were no conflicts of interest.
doi: 10.11124/jbisrir-2015-2157 Page 330

Acknowledgements
 Alexa McArthur and the staff of the Joanna Briggs Institute
 Research Centre for Nursing and Midwifery Practice, The Canberra Hospital
 My fellow Clinical Fellows
 David Larkin, Clinical Cancer Research Nurse, The Canberra Hospital
 Director of Nursing and Assistant Director of Nursing, Cancer, Ambulatory and Community
Health Support, The Canberra Hospital
doi: 10.11124/jbisrir-2015-2157 Page 331

References
1. Carrington C, Stone L, Koczwara B, Searle C, Siderov J, Stevenson B, et al. The Clinical
Oncological Society of Australia (COSA) guidelines for the safe prescribing, dispensing and
administration of cancer chemotherapy. Asia Pac J Clin Oncol. 2010;6(3): 220-37.
2. Vioral AN, Kennihan HK. Implementation of the American Society of Clinical Oncology and
Oncology Nursing Society chemotherapy safety standards. Clin J Oncol Nurs. 2012;16(6): E226-
30.
3. Henry R, Hartley B, Simpson M, Doyle N. The development and evaluation of a holistic needs
assessment and care planning learning package targeted at cancer nurses in the UK.
ecancermedicalscience. 2014;8: 416.
4. Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: a
mixed-method systematic review. J Adv Nurs. 2011;67(9): 1858-75.
5. Charm Health. CHARM™. 2014. [Internet]. [Cited July 2014]. Available from:
http://www.charmhealth.com.au/charm-products/charm/
6. Cancer Institute NSW. eviQ, Cancer Treatments online. 2014. [Internet] [Cited July 2014].
Available from: https://www.eviq.org.au/
7. Valle JW, Wasan H, Johnson P, Jones E, Dixon L, Swindell R, et al. Gemcitabine alone or in
combination with Cisplatin in patients with advanced or metastatic cholangiocarcinomas or other
biliary tract tumours: a multicentre randomized phase II study- The UK ABC-01 Study. Br J
Cancer. 2009;101(4): 621-7
8. Warnick RE, Prados MD, Mack EE, Chandler KL, Doz F, Rabbitt JE, Malec MK. A phase II study
of intravenous Carboplatin for the treatment of recurrent glioma. J Neurooncol. 1994;19(1): 69-
74.
9. Stephenson M. Chemotherapy: documentation by nursing staff (inpatient and outpatient
settings). JBI COnNECT+ (Clinical Online Network of Evidence for Care and Therapeutics).
Adelaide. 2014. [Internet]. [Cited July 2014]. Available from:
http://connect.jbiconnectplus.org/ViewDocument.aspx?0=11042
doi: 10.11124/jbisrir-2015-2157 Page 332

Appendix I: Documentation guidelines around chemotherapy administration
The following guidelines are recommended by The Clinical Oncological Society of Australia (COSA)
and The American Society of Clinical Oncology/Oncology Nursing Society (ASCO/ONS):
 Allergies - while this is initially the doctor’s responsibility, it becomes ours when checking the
patient’s ID & allergies
 Diagnosis - automatically on Charm chart
 Blood results checked
 Physical assessment - what is relevant, or document “nil complaints”
 Psychosocial assessment - what is relevant, or document “nil complaints”
 Patient education - when provided
 Consent or approval to proceed
 Verification of treatment plan (protocol), chemotherapy order and patient ID by 2 qualified

staff (CCC) each day of treatment
 Access device assessment
 Pre-medication / pre-hydration
 Chemotherapy administration according to protocol – signed and times filled in on Charm

chart
 Post-medication / post-hydration
 Toxicities / Side effects – occurrence or absence
 Self-care instructions (mouth care, skin care, anti-emetics, etc)
 Duration of cytotoxic precautions – i.e. until when
 Follow-up appointment / Next cycle
 Referral to other services – if applicable
Remember, thorough documentation not only covers you legally, but informs your colleagues and the
multidisciplinary team about the patient, ultimately assisting in the care of your patient.
doi: 10.11124/jbisrir-2015-2157 Page 333

Appendix II: Chemotherapy documentation

 Allergies
 Diagnosis - automatically on Charm chart
 Blood results checked
 Physical assessment
 Psychosocial assessment
 Patient education
 Consent or approval to proceed
 CCC- signed x 2 each day
 Access device assessment
 Pre-medication / pre-hydration
 Start & finish times completed-Charm chart
 Post-medication / post-hydration
 Toxicities / Side effects
 Self-care instructions
 Duration of cytotoxic precautions
 Follow-up appointment / Next cycle
 Referral to other services
doi: 10.11124/jbisrir-2015-2157 Page 334

Bahan 4

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Bahan 4

Uploaded by

Copyright:

Available Formats

JBI Database of Systematic Reviews & Implementation Reports 2015;13(10) 316 - 334

Documentation of chemotherapy administration by nursing staff in

1. Chemotherapy Clinical Development Nurse, Cancer, Ambulatory and Community Health

Expected Completion date: December 2014

Documentation of chemotherapy administration by nursing staff is undertaken in a written and

The aim of this evidence implementation project was to improve documentation of

doi: 10.11124/jbisrir-2015-2157 Page 316

audit; best practice; chemotherapy; documentation; evidence implementation; inpatient;

doi: 10.11124/jbisrir-2015-2157 Page 317

administration of prescribed medications, post-administration requirements and care, and safe

 Discharge medications provided.

doi: 10.11124/jbisrir-2015-2157 Page 318

Aims and objectives

The specific objectives of the project were to:

 Identify current practices in inpatient and outpatient oncology/hematology settings

 Devise an education program for chemotherapy nurses to address recommended

 Identify strategies to sustain and enhance improved chemotherapy documentation by nursing

3 Conducting a follow-up audit to assess the outcomes of the interventions implemented to

doi: 10.11124/jbisrir-2015-2157 Page 319

Phase 1: Stakeholder engagement (or team establishment) and baseline audit

Gaynor Stevenson, Director of Nursing

Denise Breust, Assistant Director of Nursing

Wendy Spencer, Clinical Nurse Consultant, Outpatient Oncology/Immunology

Kathlene Robson, Clinical Nurse Consultant, Outpatient Hematology

Sue Langdon, Clinical Nurse Consultant, Inpatient Hematology/Oncology

David Larkin PhD, Research Officer

Audit criterion Sample Method used to measure % compliance

doi: 10.11124/jbisrir-2015-2157 Page 320

Audit criterion Sample Method used to measure % compliance

doi: 10.11124/jbisrir-2015-2157 Page 321

Audit criterion Sample Method used to measure % compliance

Phase 2: Design and implementation of strategies to improve practice (GRiP)

Phase 3: Follow-up audit post implementation of change strategy

doi: 10.11124/jbisrir-2015-2157 Page 322

doi: 10.11124/jbisrir-2015-2157 Page 323

Documentation of premedication/pre-hydration (criterion 3) showed 83% compliance in the inpatient

Criterion 11 (chemotherapy nurses have received education regarding appropriate documentation

doi: 10.11124/jbisrir-2015-2157 Page 324

Phase 2: Strategies for Getting Research into Practice (GRiP)

doi: 10.11124/jbisrir-2015-2157 Page 325

“Documentation guidelines around chemotherapy administration” (Appendix I) was developed

Table 2: GRiP matrix

Barrier Strategy Resources Outcomes

doi: 10.11124/jbisrir-2015-2157 Page 326

Phase 3: Follow-up audit(s)

doi: 10.11124/jbisrir-2015-2157 Page 327

doi: 10.11124/jbisrir-2015-2157 Page 328

Criterion 11 (chemotherapy nurses have received education regarding appropriate documentation

doi: 10.11124/jbisrir-2015-2157 Page 329

In order to continue to improve and sustain thorough documentation around chemotherapy

doi: 10.11124/jbisrir-2015-2157 Page 330

 My fellow Clinical Fellows

 David Larkin, Clinical Cancer Research Nurse, The Canberra Hospital

doi: 10.11124/jbisrir-2015-2157 Page 331

doi: 10.11124/jbisrir-2015-2157 Page 332

Appendix I: Documentation guidelines around chemotherapy administration

 Diagnosis - automatically on Charm chart

 Blood results checked

 Physical assessment - what is relevant, or document “nil complaints”

 Psychosocial assessment - what is relevant, or document “nil complaints”

 Patient education - when provided

 Consent or approval to proceed

 Verification of treatment plan (protocol), chemotherapy order and patient ID by 2 qualified