1
|
Jacobson JO, Zerillo JA, Mulvey T, Stuver SO, Revette AC. Development of a taxonomy for characterising medical oncology-related patient safety and quality incidents: a novel approach. BMJ Open Qual 2022; 11:bmjoq-2022-001828. [PMID: 35793864 PMCID: PMC9260784 DOI: 10.1136/bmjoq-2022-001828] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/10/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Joseph O Jacobson
- Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica Ann Zerillo
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Therese Mulvey
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sherri O Stuver
- Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Anna C Revette
- Population Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Moghaddasi H, Rahimi R, Kazemi A, Arjmandi Rafsanjani K, Bahoush G, Rahimi F. A Clinical Decision Support System for Increasing Compliance with Protocols in Chemotherapy of Children with Acute Lymphoblastic Leukemia. Cancer Inform 2022; 21:11769351221084812. [PMID: 35342287 PMCID: PMC8943570 DOI: 10.1177/11769351221084812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 02/11/2022] [Indexed: 11/27/2022] Open
Abstract
Objective: In this survey, a protocol-based Chemotherapy Prescription Decision Support
System (CPDSS) was designed and evaluated to reduce medication errors in the
chemotherapy process of children with ALL. Methods: The CPDSS algorithm was extracted by the software development team based on
the protocol used by doctors to treat children with ALL. The ASP.Net MVC
and SQL Server 2016 programming languages were used to develop the system. A
3-step evaluation (technical, retrospective, and user satisfaction) was
performed on CPDSS designed at 2 children’s hospitals in Tehran. The data
were analyzed using descriptive statistics. At the technical evaluation
step, users provided recommendations included in the system. Results: In the retrospective CPDSS evaluation step, 1281 prescribed doses of the
drugs related to 30 patients were entered into the system. CPDSS detected
735 cases of protocol deviations and 57 (95%, CI = 1.25-2.55) errors in
prescribed chemotherapy for children with ALL. In the user satisfaction
evaluation, the users approved two dimensions of the user interface and
functionality of the system. Conclusions: With the provision of alerts, the CPDSS can help increase compliance with
chemotherapy protocols and decrease the chemotherapy prescribing errors that
can improve patient safety.
Collapse
Affiliation(s)
- Hamid Moghaddasi
- Department of Health Information Management and Technology, School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rezvan Rahimi
- Department of Medical Informatics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Alireza Kazemi
- Department of Health Information Management and Technology, School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Khadijeh Arjmandi Rafsanjani
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Bahoush
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Ali-Asghar Children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Forough Rahimi
- School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| |
Collapse
|
3
|
Zakaria OM, Hokkam EN, Sayem KA, Daoud MYI, Zakaria HM, Sedky F, Graiz SH, Moussa SA, Wadaani HAA. Initial Surgery in Tailoring Treatment for Children With Stage II and III Wilms' Tumor: An Experience From Resource Challenged Settings. World J Oncol 2015; 6:441-445. [PMID: 28983345 PMCID: PMC5624669 DOI: 10.14740/wjon876w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Although Wilms' tumor (WT) is ranked first among primary childhood's renal neoplasm, controversy still exists regarding the best approach for its management. The study aimed at evaluating the role of initial surgery in treatment of stage II and III pediatric WT as a part of the short administration schedule as in National Wilms' Tumor Study (NWTS)-4 and evaluating its effectiveness compared to the long administration schedule. METHODS The study included 30 children who were primarily diagnosed as stage II and III WT. They were divided into two equal groups. Group I (n = 15) included those children who had undergone neoadjuvant chemotherapy followed by surgery and postoperative chemotherapy, while group II (n = 15) included those children who had undergone primary surgery as an initial management followed by chemotherapy. After a mean postoperative follow-up period of 14 ± 5 months, clinical and radiological evaluation was performed to all patients. RESULTS In group I, 10 patients were preoperatively diagnosed as stage II and five patients as stage III while in group II, 11 patients were proved to be stage II and four patients were stage III. After a follow-up period, clinical and radiological evaluation using CT was performed to all patients. In patients with stage II, evidence of recurrence was noted in three patients of group I whereas no patient showed any evidence of recurrence in group II. In patients with stage III, rebound increase in size was seen in two patients in group I and only one patient in group II. CONCLUSIONS Initial surgical intervention with appropriate adjuvant therapy has better outcomes than the neoadjuvant chemotherapy and delayed surgery for children primarily diagnosed as stage II and III WT. Moreover, it may act as a short administration schedule for the treatment as it is not less effective than the long administration schedule and can be administered at a substantially lower total treatment cost.
Collapse
Affiliation(s)
- Ossama M Zakaria
- Department of Surgery, College of Medicine, King Faisal University, Al Ahsa, KSA.,Department of Surgery, College of Medicine, Dammam University, KSA
| | - Emad N Hokkam
- Department of Surgery, Faculty of Medicine, Suez Canal University, Egypt
| | - Karam Al Sayem
- Department of Surgery, Faculty of Medicine, Suez Canal University, Egypt
| | | | - Hazem M Zakaria
- Department of Surgery, College of Medicine, Dammam University, KSA
| | - Fouad Sedky
- Department of Surgery, College of Medicine, Dammam University, KSA
| | - Seba H Graiz
- Department of Surgery, College of Medicine, King Faisal University, Al Ahsa, KSA
| | | | - Hamed A Al Wadaani
- Department of Surgery, College of Medicine, King Faisal University, Al Ahsa, KSA
| |
Collapse
|
4
|
Nwozichi CU. Why are chemotherapy administration errors not reported? Perceptions of oncology nurses in a Nigerian tertiary health institution. Asia Pac J Oncol Nurs 2015; 2:26-34. [PMID: 27981089 PMCID: PMC5123459 DOI: 10.4103/2347-5625.152403] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 12/29/2014] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The administration of chemotherapy forms a major part of the clinical role of oncology nurses. When a mistake is made during chemotherapy administration, admitting and reporting the error timely could save the lives of cancer patients. The main objective of this study was to assess the perceptions of oncology nurses about why chemotherapy administration errors are not reported. METHODS This is a descriptive study that surveyed a convenient sample of 128 oncology nurses currently practicing in the Ogun State University Teaching Hospital, Nigeria. The tool for data collection was a structured questionnaire that consisted of two sections. The first section was for the demographic data of participants and the second section consisted of questions constructed based on the Medication Administration Error (MAE) reporting survey developed by Wakefield and his team. RESULTS Findings showed that majority of the nurses (89.8%) have made at least one MAE in the course of their professional practice. Fear (mean = 3.63) and managerial response (mean = 2.87) were the two major barriers to MAE reporting perceived among oncology nurses. CONCLUSION Critically analyzing why medication errors are not reported among oncology nurses is crucial to identifying strategic interventions that would promote reporting of all errors, especially those related to chemotherapy administration. It is therefore recommended that nurse managers and health care administrators should create a favorable atmosphere that does not only prevent medication errors but also supports nurses' voluntary reporting of MAEs. Education, information and communication strategies should also be put in place to train nurses on the need to report, if possible prevent, all medication errors.
Collapse
Affiliation(s)
- Chinomso Ugochukwu Nwozichi
- Department of Adult Health Nursing, School of Nursing, Babcock University, Ilishan Remo, Ogun State, Nigeria
| |
Collapse
|
5
|
Harris N, Badr LK, Saab R, Khalidi A. Caregivers' perception of drug administration safety for pediatric oncology patients. J Pediatr Oncol Nurs 2014; 31:95-103. [PMID: 24569227 DOI: 10.1177/1043454213517749] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Medication errors (MEs) are reported to be between 1.5% and 90% depending on many factors, such as type of the institution where data were collected and the method to identify the errors. More significantly, the risk for errors with potential for harm is 3 times higher for children, especially those receiving chemotherapy. Few studies have been published on averting such errors with children and none on how caregivers perceive their role in preventing such errors. The purpose of this study was to evaluate pediatric oncology patient's caregivers' perception of drug administration safety and their willingness to be involved in averting such errors. A cross-sectional design was used to study a nonrandomized sample of 100 caregivers of pediatric oncology patients. Ninety-six of the caregivers surveyed were well informed about the medications their children receive and were ready to participate in error prevention strategies. However, an underestimation of potential errors uncovered a high level of "trust" for the staff. Caregivers echoed their apprehension for being responsible for potential errors. Caregivers are a valuable resource to intercept medication errors. However, caregivers may be hesitant to actively communicate their fears with health professionals. Interventions that aim at encouraging caregivers to engage in the safety of their children are recommended.
Collapse
|
6
|
Kullberg A, Larsen J, Sharp L. 'Why is there another person's name on my infusion bag?' Patient safety in chemotherapy care - a review of the literature. Eur J Oncol Nurs 2012; 17:228-35. [PMID: 22898657 DOI: 10.1016/j.ejon.2012.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 07/05/2012] [Accepted: 07/11/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE Approximately 10% of all patients is in some way harmed by the health care system. Risk factors have been identified and patients with cancer are at high risk due to the seriousness of the disease, co-morbidity, often old age, high risk treatments such as chemo and radiotherapy. Therefore, a closer look on safety for patients undergoing chemotherapy is needed. The aim of this study was to identify and evaluate interventions for improved patient safety in chemotherapy care. METHOD We undertook a review of the available evidence regarding interventions to improve patient safety in relation to chemotherapy care. RESULTS We found 12 studies describing the following interventions; 1) Computerized Prescription Order Entry (CPOE), 2) Failure Mode and Effect Analysis (FMEA) and Lean Sigma, 3) Error reporting and surveillance systems, 4) Administration Checklist and 5) Education for nurses. Even if all five interventions showed positive effects in patient safety, the evidence level is rather weak due to design, sample size and the difficulties involved measuring patient safety issues. CONCLUSIONS Three studies with fairly high evidence level showed that computerized chemotherapy prescriptions were significantly safer than manual prescriptions and could therefore be recommended. For the other remaining interventions, more research is needed to assess the effect on improved patient safety in chemotherapy care. There is a need for more rigorous studies with sophisticated design for generating evidence in the field.
Collapse
Affiliation(s)
- Anna Kullberg
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden.
| | | | | |
Collapse
|
7
|
Miller MR, Robinson KA, Lubomski LH, Rinke ML, Pronovost PJ. Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care 2007; 16:116-26. [PMID: 17403758 PMCID: PMC2653149 DOI: 10.1136/qshc.2006.019950] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Although children are at the greatest risk for medication errors, little is known about the overall epidemiology of these errors, where the gaps are in our knowledge, and to what extent national medication error reduction strategies focus on children. OBJECTIVE To synthesise peer reviewed knowledge on children's medication errors and on recommendations to improve paediatric medication safety by a systematic literature review. DATA SOURCES PubMed, Embase and Cinahl from 1 January 2000 to 30 April 2005, and 11 national entities that have disseminated recommendations to improve medication safety. STUDY SELECTION Inclusion criteria were peer reviewed original data in English language. Studies that did not separately report paediatric data were excluded. DATA EXTRACTION Two reviewers screened articles for eligibility and for data extraction, and screened all national medication error reduction strategies for relevance to children. DATA SYNTHESIS From 358 articles identified, 31 were included for data extraction. The definition of medication error was non-uniform across the studies. Dispensing and administering errors were the most poorly and non-uniformly evaluated. Overall, the distributional epidemiological estimates of the relative percentages of paediatric error types were: prescribing 3-37%, dispensing 5-58%, administering 72-75%, and documentation 17-21%. 26 unique recommendations for strategies to reduce medication errors were identified; none were based on paediatric evidence. CONCLUSIONS Medication errors occur across the entire spectrum of prescribing, dispensing, and administering, are common, and have a myriad of non-evidence based potential reduction strategies. Further research in this area needs a firmer standardisation for items such as dose ranges and definitions of medication errors, broader scope beyond inpatient prescribing errors, and prioritisation of implementation of medication error reduction strategies.
Collapse
Affiliation(s)
- Marlene R Miller
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA.
| | | | | | | | | |
Collapse
|
8
|
Rinke ML, Shore AD, Morlock L, Hicks RW, Miller MR. Characteristics of pediatric chemotherapy medication errors in a national error reporting database. Cancer 2007; 110:186-95. [PMID: 17530619 DOI: 10.1002/cncr.22742] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Little is known regarding chemotherapy medication errors in pediatrics despite studies suggesting high rates of overall pediatric medication errors. In this study, the authors examined patterns in pediatric chemotherapy errors. METHODS The authors queried the United States Pharmacopeia MEDMARX database, a national, voluntary, Internet-accessible error reporting system, for all error reports from 1999 through 2004 that involved chemotherapy medications and patients aged <18 years. RESULTS Of the 310 pediatric chemotherapy error reports, 85% reached the patient, and 15.6% required additional patient monitoring or therapeutic intervention. Forty-eight percent of errors originated in the administering phase of medication delivery, and 30% originated in the drug-dispensing phase. Of the 387 medications cited, 39.5% were antimetabolites, 14.0% were alkylating agents, 9.3% were anthracyclines, and 9.3% were topoisomerase inhibitors. The most commonly involved chemotherapeutic agents were methotrexate (15.3%), cytarabine (12.1%), and etoposide (8.3%). The most common error types were improper dose/quantity (22.9% of 327 cited error types), wrong time (22.6%), omission error (14.1%), and wrong administration technique/wrong route (12.2%). The most common error causes were performance deficit (41.3% of 547 cited error causes), equipment and medication delivery devices (12.4%), communication (8.8%), knowledge deficit (6.8%), and written order errors (5.5%). Four of the 5 most serious errors occurred at community hospitals. CONCLUSIONS Pediatric chemotherapy errors often reached the patient, potentially were harmful, and differed in quality between outpatient and inpatient areas. This study indicated which chemotherapeutic agents most often were involved in errors and that administering errors were common. Investigation is needed regarding targeted medication administration safeguards for these high-risk medications.
Collapse
Affiliation(s)
- Michael L Rinke
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | | | | | | |
Collapse
|