Weve done several columns (listed below) on the dangers of home infusion therapy for cancer chemotherapy agents. In most cases the dangers have arisen when an agent intended to be infused over several days is instead infused over several hours, leading to toxicity and, in some cases, death.
But cancer chemotherapy is not the only type of home infusion therapy that may be dangerous. ISMP Canada (ISMP Canada 2016) recently did a column about a fatal case related to intravenous vancomycin therapy in the home but their excellent recommendations apply to almost any type of home infusion therapy.
The case described was a diabetic patient with a foot ulcer who was receiving IV vancomycin at home after a hospital stay. Recommended bloodwork, including trough vancomycin levels, was not done due to a faulty lab requisition. The patient developed a rash, thrombocytopenia, and high serum vancomycin levels as well as rising creatinine. He was rehospitalized but despite IV fluids and platelet transfusions, he developed hypertensive episodes, epistaxis and mental status changes and developed intracerebral bleeding and ultimately died. The acute kidney injury was attributed to vancomycin toxicity and the thrombocytopenia was also felt possibly related to the vancomycin.
ISMP Canada makes recommendations that are appropriate not only for home vancomycin infusions but also for any drug requiring therapeutic drug monitoring. Good planning prior to discharge is critical. The prescriber should decide whether an oral agent or an intravenous agent not requiring therapeutic drug monitoring might be an alternative therapy. The team should determine whether all the treatment and monitoring needs can, in fact, be met with homecare (as opposed to followup in a hospital ambulatory setting or continued inpatient admission). They should liaise with the most responsible health care provider who will be responsible for ongoing monitoring and assessment of the patient in the community prior to the patients discharge. Copies of any laboratory requisitions and any special instructions should be provided. Prescriptions and completed laboratory requisitions should be provided and they recommend avoiding Friday bloodwork since results may be delayed over weekends or holidays. Particularly important with potentially nephrotoxic drugs like vancomycin is a review and possible adjustment of any concomitant medications that might promote nephrotoxicity. The latest bloodwork should be reviewed before administering each dose of the drug. In addition to discussing the care plans with the home health agencies and/or community pharmacists, it is important that the patient or family be educated on the importance of getting the bloodwork done and what signs or symptoms should raise concerns. Hospital pharmacists familiar with the therapeutic drug monitoring should be part of the discharge team and may serve as the liaison with community pharmacists where appropriate.
The article also has a link to ISMP Canadas transitions toolkit and checklist, a very valuable resource for facilitating safe discharge of patients.
But what happens at home is not the only problem with home infusion. ISMP (US) notes that home infusion therapies may also give rise to problems when such patients are admitted to hospitals or emergency departments (ISMP 2015). ISMP notes that patient safety can be jeopardized if the devices are mishandled when filling, programming, attaching, and monitoring the pumps and that the ambulatory pump marketplace is diverse, so the devices rarely have standard components. Therefore, serious errors can occur when healthcare providers are not familiar with these ambulatory pumps. The classic problematic one is the insulin pump, as weve described in several columns, because the vast majority of healthcare workers are not familiar with its use. Healthcare workers may not know whether the pump is functioning properly nor how to get replacement parts or batteries. There have also been cases where a physician orders and a nurse gives a dose of insulin after a patient has administered a dose without telling them. Every hospital should have a team headed by an endocrinologist who can manage insulin pumps in the hospital. That may be a challenge for rural hospitals, though use of telemedicine may help.
Our prior columns related to chemotherapy safety:
Some of our prior columns on medication errors in other ambulatory settings:
June 12, 2007
August 14, 2007
March 24, 2009
October 16, 2007
January 15, 2008
April 2010 Medication Incidents Related to Cancer Chemotherapy
September 2010 Beers List and CPOE
October 19, 2010
April 12, 2011 Medication Issues in the Ambulatory Setting
June 2012 Parents' Math Ability Matters
May 7, 2013 Drug Errors in the Home
May 5, 2015 Errors with Oral Oncology Drugs
September 15, 2015 Another Possible Good Use of a Checklist
April 19, 2016
June 21, 2016
ISMP Canada. Gaps in Transition: Management of Intravenous Vancomycin Therapy in the Home and Community Settings. ISMP Canada Safety Bulletin 2016; 16(4): 1-5 June 28, 2016
ISMP Canada. Hospital to Home - Facilitating Medication Safety at Transitions. A Toolkit and Checklist for Healthcare Providers.
ISMP (Institute for Safe Medication Practices). Ambulatory pump safety: Managing home infusion patients admitted to the ED and hospital. ISMP Medication Safety Alert! Acute Care Edition 2015; September 10, 2015