264 Background: Despite clear advantages of Electronic Health Records (EHR) systems for safe cancer chemotherapy administration, persistent opportunities exist to further reduce chemotherapy order errors. Unintended dose escalation orders of previously dose reduced chemotherapy were the most commonly reported “near-miss” medication safety events at our institution. This can lead to potential patient harm, delays in care, decreased patient satisfaction, reduced infusion room efficiency, and increased care team workload and decreased satisfaction. We sought to reduce chemotherapy order errors using interventions developed with process improvement techniques. Methods: Unintended dose escalation errors per month (the primary outcome measure) were identified through the hospital safety reporting system and by monitoring the EHR (EPIC) chemotherapy administration reports to identify dose escalations. All cases were confirmed with primary chart review. The pre-intervention baseline assessment period was 6/2017-11/2017, and the post intervention period was 12/2017-5/2018. Two interventions were selected: 1) Revision of the nursing chemotherapy checklist posted on all infusion room workstations for use prior to releasing chemotherapy orders; and 2) educating ordering providers and nurses about new EHR functionality to display prior and future chemotherapy orders. Statistical Process Control chart analysis was conducted with upper (UCL) and lower (LCL) control limits of 3 standard deviations. The primary aim was to reduce the number of chemotherapy errors by 50% in the post-intervention period. Results: The pre-intervention period averaged 3.83 chemotherapy ordering errors per month (UCL = 9.71, LCL = 0). The post-intervention period significantly reduced the average errors per month to 1.33 (UCL = 4.97, LCL = 0). The copy/forward feature in multi-day cycles was the most common source of unintended dose escalations. Conclusions: Implementation of the 2 interventions resulted in a 65% reduction of unintended dose modification errors. Based on successful results and positive staff feedback, we plan to roll out these interventions at additional satellite facilities.
Cancer Morbidity, Mortality, and Improvement Rounds is a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. For purposes of clarity, each case focuses on a single theme, although, as is true for all medical incidents, there are almost always multiple, overlapping, contributing factors. The quality improvement paradigm used here, which focuses on root cause analyses and opportunities to improve care delivery systems, was previously outlined in this journal. This article describes the care of a young patient with aggressive breast cancer, declining performance status, and multiple hospital admissions who died shortly after being discharged home without essential medications or an adequate plan for follow-up. The patient's death due to her malignancy was unavoidable, but she had inadequate resources before her death, leading to avoidable suffering. This outcome resulted from a series of minor errors attributable to inadequate handoffs, challenges establishing realistic goals of care, and hierarchy within and between medical teams that resulted in major lapses at the time of discharge. We explore these issues and discuss how this case led to the establishment of programs designed to empower health care providers and increase engagement of outpatient oncologists at critical points of patients' disease courses.
141 Background: Patient Reported Outcomes CTCAE (PROM) completion has demonstrated improvements in survival for patients with advanced cancer. Little is known about completion rates by race and gender for questionnaires assigned to all patients receiving IV infusions. Methods: Beginning in 2019 all patients who had a visit associated with an IV infusion were assigned a PROM PRO-CTCAE questionnaire through the EHR portal 72 hours prior to the visit and again using an in- clinic tablet if not completed upon check-in. The PROMs questionnaires are available in 6 languages via both electronic platforms. At registration, all patients self- identify as White, Black/African American, Asian or other (multiple, do not prefer to answer) by race. We collected 2021 data on all eligible patients who were assigned a questionnaire and cross referenced that by completion and self-assigned race and gender at registration. Data from breast, thoracic and GI clinics are presented. Results: 1715 patients were eligible and self-identified as White, Black or Asian for a PROM CTCAE questionnaire across the three clinics (519 breast clinic, 390 thoracic, 806 GI). 3872 questionnaires were completed (average 2.26 questionnaires per eligible patient). 2875 (73%) were completed by EHR portal and 1027 (27%) were completed in clinic on the tablet. White patients completed questionnaires 67% when assigned, Asian 68% and Black/African American 52% of the time. 81% of breast clinic patients completed questionnaires, 62% of thoracic patients and 54% of GI patients. Overall, in thoracic and GI clinics White women completed questionnaires 58%, Black women 41% and Asian women 70% compared to White men 59%, Asian men 56% and Black men 57%. All patients who completed questionnaires in breast clinic identified as women. Conclusions: We assigned PROM CTCAE questionnaires to all eligible patients who had an IV infusion encounter associated with their visits in the breast, thoracic and GI clinics by both the electronic chart portal and again in clinic by tablet, if not completed prior to the in person visit. PROM questionnaires are available in 6 languages through both methods. We identified differences in completion rates by race with fewer African American/Black patient completion rates compared to White or Asian self-identification, (52% vs 67.5%). The largest differences were between White or Asian women, 58% and 70% completion rates compared to Black women 41%. Differences in gender may explain differences across disease groups as all breast clinic patients were self-identified as female, 81% completion rate compared to 62% thoracic and 54% GI.
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