Aim To reduce the incidence of omitted or delayed doses of IV folinic acid rescue following the implementation of electronic prescribing.
High dose methotrexate (MTX) is a component of some paediatric chemotherapy regimens. IV folinic acid rescue started 24–42 hours after MTX (dependent on protocol) is essential to avoid toxicity. Since the introduction of electronic prescribing (EP) there has been an increase in the number of delayed doses of folinic acid. Prior to the introduction of EP, this rescue was prescribed alongside the chemotherapy on the paper chart, allowing nurses to enter the folinic acid start time at the same time as starting the MTX. It is not possible to do this with the EP system.
Method A list of all patients who have received high dose methotrexate since December 2012 was compiled and drugs charts reviewed to check the folinic acid prescription and administration. An audit tool was created to collect the data. Any new patients prescribed high dose methotrexate were audited prospectively. In addition the Trust incident database was interrogated for all previous reports of omitted/delayed doses of folinic acid to ensure all cases were captured.
Several changes including checklists, paper and electronic based prompts have been implemented in an effort to resolve the problem. A retrospective audit and ongoing review of new prescriptions is being completed, identifying the compliance with the new measures and percentage of prescriptions where folinic acid has been prescribed and given at the correct time.
Results In the ten month period prior to EP, 100% of prescriptions for folinic acid were complete and administered correctly. This reduced to 83% immediately following the introduction of EP. After the introduction of the first set of measures this increased to 94%.
Conclusion Since the implementation of EP ongoing changes to the prescribing of folinic acid are helping to reduce the incidents of delayed and omitted doses. Continuous monitoring will enable deficiencies in our systems to be highlighted and resolved in a timely fashion in order to avoid a potentially serious adverse event. Further changes to our procedures are currently being evaluated, with an expectation that 100% compliance will be achieved.
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