Significant and Sustained Reduction in Chemotherapy Errors Through Improvement Science

Weiss, Brian; Scott, Melissa; Demmel, Kathleen Marie; Kotagal, Uma R.; Perentesis, John P.; Walsh, Kathleen E.

doi:10.1200/jop.2017.020842

Cited by 11 publications

(26 citation statements)

References 22 publications

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“…This is also supported by recent research suggesting that chemotherapy errors with CPOE may be prevented with knowledge of a patient's chemotherapy history and in-depth knowledge of protocols (41). Nurses' and/or pharmacists' routine checks of CPOE orders against protocols (22,24) -also reported in the unit we studied -are one way to address CPOE limitations by automatically monitoring variations to protocols, and may also be facilitated by the availability of electronic roadmap displays.…”

Section: Discussionmentioning

confidence: 99%

“…The literature suggests that design of CPOE for chemotherapy is 'confronted with problems' (21) and that CPOE alone is not su cient to eliminate chemotherapy errors. Other safety strategies generally co-exist, including error surveillance systems (22,23), checking of patient regimens against standard protocols (22,24), and interventions to improve situational awareness (12,22). The literature remains unclear on how CPOE relates to such strategies, especially with regard to management of interdependencies.…”

Section: Introductionmentioning

confidence: 99%

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Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

Lichtner

Franklin

Dalla‐Pozza

et al. 2020

Preprint

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Background: There are serious safety risks associated with chemotherapy, often associated with interdependencies in regimens administered over months or years. Various strategies are used to manage these risks. Computerized provider order entry (CPOE) systems are also implemented to improve medication safety. Little is known regarding the effect of CPOE on how clinicians manage chemotherapy interdependencies and their associated safety strategies.Methods: We conducted a multi-method qualitative study in a paediatric hospital. We analysed 827 oncology incidents reported following CPOE implementation and carried out semi-structured interviews with doctors (n=10), nurses (n=6), a pharmacist, and oncology CPOE team members (n=2). Results were interpreted according to safety models (ultra-safe, high-reliability organisations [HROs], or ultra-adaptive). Results: Incident reports highlighted two interrelated types of interdependencies: those within organisation of clinical activities and those inherent in chemotherapy regimens. Clinicians reported strategies to address chemotherapy risks and interdependencies. These included rigid rules and ‘no go’ contexts for treatment to proceed, typical of the ultra-safe model; use of time (e.g. planning only so far ahead) and sensitivity to operations, typical of HROs. We identified three different time horizons in CPOE use in relation to patients’ treatments: life-long, the whole regimen, and the ‘here and now’. CPOE supported ultra-safe strategies through automation and access to rules/standardisation, but also created difficulties and contributed to incidents. It supported the ‘here and now’ better than a life-long or whole regimen view of a patient treatment. Sensitivity to operations was essential to anticipate and resolve uncertainties, hazards, CPOE limitations, and mismatches between CPOE processes and workflow in practice. Conclusions: Within oncology, CPOE appears to move the ‘mix’ of risk strategies towards ultra-safe models of safety and protocol-mandated care. However, in order to operate ultra-safe strategies embedded in CPOE and stay on protocol it is essential for clinicians to be thoughtful and show sensitivity to operations in CPOE use. CPOE design can be advanced by better consideration of mechanisms to support interdependencies.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

Lichtner

Franklin

Dalla‐Pozza

et al. 2020

Preprint

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“…With the information that medication administration errors are the most common errors to reach patients, Weiss et al [4] created a chemotherapy safety working group at a large urban pediatric medical center. They initiated a daily chemotherapy safety huddle that takes place every afternoon and includes charge nurses, fellows, attending physicians, hospitalists, nurse practitioners, care managers, a pharmacist, and a chemotherapy safety officer.…”

Section: Available Knowledgementioning

confidence: 99%

“…Other interventions targeted reducing distractions while clinicians ordered chemotherapy, a new workflow to address leaking chemotherapy lines, development of a timesequencing job aid to determine the correct time of administration for time-sensitive medications, and requirement that chemotherapy is written at least 1 week in advance. With these interventions, they saw a sustained 50% reduction in chemotherapy errors that reached patients [4].…”

Section: Available Knowledgementioning

confidence: 99%

“…Medication errors are the most common cause of adverse events in the inpatient setting; these errors are largely due to prescribing and administration errors [2,3]. Children are at a unique risk because of varying dosage forms, concentrations, and formulations that must be reconstituted from powder and weight-based dosing, with error rates per patient-days greater in pediatric intensive care units [1,4,5]. The most frequently involved classes of drugs in medication errors are antibiotics and antitumor agents [6À8].…”

Section: Introductionmentioning

confidence: 99%

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Improving the Timeliness of Chemotherapy Administration in the Bone Marrow Transplant Unit

Bhandari

Orgel

Rushing

et al. 2020

Biology of Blood and Marrow Transplantation

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Patients undergoing hematopoietic stem cell transplantation (HSCT) are often admitted to the hospital the day they are due to begin their conditioning regimen. Timely initiation of chemotherapy during regular work hours is important for patient safety, because during the night shift fewer physicians and pharmacists are available for urgent or unexpected matters. A review of the data at our institution from October 2017 to August 2018 showed that approximately one-third of our chemotherapy was started during the night shift (after 19:00), and the average time from admission to start of chemotherapy was over 8 hours. There are currently no well-defined benchmarks for timeliness of chemotherapy initiation. The aim of this quality improvement initiative was to increase the percentage of patients who start chemotherapy in the bone marrow transplant unit before 19:00 from 65% to >80% by March 31, 2019. We identified barriers to timely initiation of chemotherapy through process mapping and analysis of failures. The primary barriers were late admissions (after 12:00 pm) and time from admission to preparation of chemotherapy. We addressed mechanisms to mitigate these barriers through Plan-Do-Study-Act testing. Interventions included providing families specific admission times and their rationales and process for notifying pharmacy of admissions immediately on arrival. We used standardized control charts to measure the impact of the interventions on change. We also monitored medication errors before and during the intervention. From September 2018 to March 2019 the percentage of patients who started preparative chemotherapy before 19:00 increased from 65% to 85%, the percentage of patients who were admitted after 12:00 remained similar before (31%) and after the interventions (33%), and the average time from admission to start of chemotherapy decreased from 8.6 hours (513 minutes) to 6.4 hours (382 minutes). Medication errors were similar before (n = 50) and after the interventions (n = 43). Using standardized processes, we demonstrated a substantial decrease in the percentage of HSCT patients starting their preparative regimen after 19:00 without a concurrent increase in errors. We believe these interventions and measurements can be used in all transplant centers and have the potential to influence patient safety and outcomes.

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Quality Improvement in Hematopoietic Stem Cell Transplant and Cellular Therapy: Using the Model for Improvement to impact Outcomes

Kapadia

Lehmann

Auletta

et al. 2022

Transplantation and Cellular Therapy

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Significant and Sustained Reduction in Chemotherapy Errors Through Improvement Science

Abstract: After the model for improvement, our improvement efforts were associated with significant reductions in chemotherapy errors that reached the patient. Key drivers for our success included error vigilance through a huddle, standardization, and minimization of interruptions during ordering.

Cited by 11 publications

References 22 publications

Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

Improving the Timeliness of Chemotherapy Administration in the Bone Marrow Transplant Unit

Quality Improvement in Hematopoietic Stem Cell Transplant and Cellular Therapy: Using the Model for Improvement to impact Outcomes

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