Table 2 Ultra-safe strategies to avoid medication errors/unwanted protocols’ variations: automation and ‘soft’ support

Treatment is independent of specific clinicians

Visibility and access to protocol rules and a patient prescribed treatment

[...] your treatment has to go ahead whether I’m alive, dead, overseas [...] someone else has to bear the brunt of knowing where they’re at. So it’s really crucial for us to have a system whereby the – ‘where they’re at’ is easily accessible, (id1)

Everyone knows/has access to the rules

Visibility and access to protocol rules and a patient prescribed treatment

...we have got immediate access to what the protocol looks like and [...] to the documentation. [...] they’re not squirreled away in some cupboard, they’re not lost, they’re available electronic everywhere. (id1)

[nurses would] go to the orders page. [...] And they’ll go okay, so he’s in hospital [...], so he came in on Sunday, tomorrow he’s due vincristine. I have to make sure I check with the doctors, whether they want him to go ahead with it or delay it, which they would never have known in advance, previously. They’d never have been able to see that. Because they didn’t have any of their chemotherapy records when they got admitted. [...] Their visibility of it is probably one of the most important things of the plans. (id14)

Standardised protocols across patients and clinicians

Disambiguation of protocol rules

… whether an or and a comma in a sentence meant one thing was inclusive of another, or one thing was exclusive of another. So even within protocols, even the smallest wording, [...] you’ve really got to sit down and discuss as a team what you think it means, … (id13)

Rules on the content of the prescription (as per protocol)

CPOE templates, with linked pre-set orders

Automatic calculations by embedded rules

Warnings about breaking rules

...depending on the drugs that go into [the CPOE plans] and how they relate to each other [...] they might [...] have a timed relationship to say you’re not allowed to start drug Y until drug X has finished or run them both at the same time... (id13)

You’re meant to give this over four hours, [...] - in paper, that was just written and then pharmacy would come along and, kind of, annotate it, whereas now it’s prebuilt ... (id7)

all the drugs listed here, you just have to agree to it [...] [the CPOE system] will limit dose, [system says two] you can’t order two and a half. So there are certain protections in the system... (id1)

Rules on who can act on the prescription

Users’ profiles and workflow management systems to route the prescription

... [the fellows] – they can sign it but it doesn’t go to pharmacy until it’s [gone] to the oncologist. [...] Once [the oncologist] reviewed it, it goes to pharmacy. [...] [Pharmacy] can’t make it up until [it’s been reviewed by the oncologist]. (id1)

Treatment stopped until patient recovers [‘Plan A’]

‘Ready for chemo’ checkbox – no administration until ‘ticked’

...there is a flow that says, well say it’s more than 30 white cells, [...], liver function is less than that, [...] very clear criteria and then only if you tick them and if they are okay will it allow you to go ahead and sign for a go ahead. (id2)

Checks along the process

Double signatures required to unlock next step

...we are much more rigid in terms of two people checking, two people going to the bedside. (id8–12)

Checks against the rules

Nurses verifying treatment based on access to the protocol

... [before CPOE] you had to have the paper protocol [...] [with the CPOE] the nurses [...] [have] access to the protocol. So, when they saw a particular dose scheduled, they would go to the protocol, check it and say ‘yes’. And, [...] if it didn’t marry, then they would report it as an incident ... (id16)