Ong Michal Wen Sheue, Jones Lydia
Epsom General Hospital, United Kingdom.
BMJ Qual Improv Rep. 2017 Mar 31;6(1). doi: 10.1136/bmjquality.u206586.w4692. eCollection 2017.
This project was started after an incident of bisphosphonate-induced hypocalcaemia in September 2015. As part of management of lytic bone lesions in patients with multiple myeloma were given either Zoledronic Acid or Pamidronate Disodium at our Haematology Day Unit. According to the British National Formulary (BNF), it is necessary to correct disturbances of calcium metabolism (e.g. vitamin D deficiency, hypocalcaemia) and consider dental check-ups before starting bisphosphonate infusion due to the risk of osteonecrosis of the jaw. There was no formal checklist in place for all patients prior to starting bisphosphonate infusion. The aim of this quality improvement project was (1) to avoid preventable bisphosphonate induced adverse effects, (2) to improve safety of bisphosphonate prescribing and administration and (3) to increase patient's awareness of needing regular dental checks. Interventions were modified over multiple Plan-Do-Study-Act (PDSA) improvement cycles to improve bisphosphonate infusion monitoring and patient safety.There was an overall improvement in ensuring safety checks were done prior to administration of bisphosphonate infusion compared to baseline measurements. At baseline, 36% (n=9) of patients had a dental check within the last 6 months; after PDSA cycle 3, there was an improvement of up to 69% (n=11). All patients had renal function and bone profile checked prior to infusion from throughout the study. It was all recorded in the blood results section of the checklist with no missing data. We found that 32% (n=8) of patients had never had 25-OHD at baseline. After PDSA cycle 3, all patients had 25-OHD checked at some point.
该项目始于2015年9月一起双膦酸盐诱发低钙血症事件之后。作为多发性骨髓瘤患者溶骨性骨病变管理的一部分，我们血液科日间病房的患者接受了唑来膦酸或帕米膦酸二钠治疗。根据《英国国家处方集》（BNF），由于存在颌骨坏死风险，在开始双膦酸盐输注前，有必要纠正钙代谢紊乱（如维生素D缺乏、低钙血症）并考虑进行牙科检查。在开始双膦酸盐输注前，没有针对所有患者的正式检查表。这个质量改进项目的目标是：（1）避免可预防的双膦酸盐诱发的不良反应；（2）提高双膦酸盐处方和给药的安全性；（3）提高患者对定期牙科检查必要性的认识。通过多个计划-实施-研究-改进（PDSA）改进周期对干预措施进行了调整，以改善双膦酸盐输注监测和患者安全。与基线测量相比，在确保双膦酸盐输注前进行安全检查方面有了总体改善。在基线时，36%（n = 9）的患者在过去6个月内进行了牙科检查；在PDSA周期3之后，这一比例提高到了69%（n = 11）。在整个研究过程中，所有患者在输注前都进行了肾功能和骨代谢指标检查。所有结果都记录在检查表的血液检查部分，没有缺失数据。我们发现，在基线时，32%（n = 8）的患者从未检测过25-羟基维生素D。在PDSA周期3之后，所有患者在某个时间点都进行了25-羟基维生素D检测。
