Medication errors among adults and children with cancer in the outpatient setting

Direct Clinical Pharmacist-Patient Telephone Follow-Up: A Focus on GI Medical Oncology Symptom Management

PURPOSE

GI medical oncology care presents unique medication challenges. Here, we captured our clinical pharmacy specialists' (CPSs) involvement in patients with GI cancers starting cycle 1 of a new treatment.

METHODS

Our quality initiative was performed in three stages (preintervention, intervention, and postintervention). Preintervention: retrospective baseline data collection from May to December 2019. Intervention: one-time telephone encounters were conducted by a CPS between March 15 and June 11, 2021. The primary objective of the quality improvement initiative was to increase patient interaction with a CPS to 80%. Postintervention: data collection to review the impact of CPS telephone encounters.

RESULTS

Preintervention: we reviewed the electronic health records of 262 patients. Sixty nine percent of patients reported at least one adverse event (AE; range 1-6 AEs) at the first physician follow-up after treatment start. Most reported AEs (78%) were considered modifiable within the scope of CPS practice. Postintervention: during the intervention, 92% of patients (n = 389) received a telehealth encounter with the CPS. At the encounter, 315 patients (81%) reported at least one AE. CPS provided recommendations and/or additional education for 88% of reported AEs. Medication lists required correction 75% of the time. The median time for CPS encounters (including documentation) was 40 minutes.

CONCLUSION

During a 3-month period, this quality improvement initiative successfully provided an early CPS-based telehealth intervention to identify and make initial recommendations for management of AEs for patients on cycle 1 of systemic therapy for GI cancer.

Impact of pharmacist-led interventions on medication-related problems among patients treated for cancer: A systematic review and meta-analysis of randomized control trials

BACKGROUND

Medication-related problems (MRPs) continue to impose a voluminous health impact, particularly among patients on anti-cancer therapy, due to the nature and complexity of the care. Pharmacists have a pivotal role in ensuring the safe, effective, and rational use of medicines in this group of patients.

OBJECTIVES

To examine the impact of pharmacist-led interventions in resolving MRPs among patients treated for cancer.

METHODS

This systematic review and meta-analysis was conducted and reported following the PRISMA protocol and registered in PROSPERO (Registration number: CRD42022311535). Four database searches, PubMed, EMBASE, Cochrane, and International Pharmaceuticals Abstracts, were systematically searched from August 2022 to January 2023. Only randomized control trials (RCTs) were included. The Cochrane risk of bias assessment tool was used to check the quality of the included studies. The outcome measures were overall MRPs, adherence, medication errors, and adverse drug events (ADEs). Data for meta-analysis were analyzed used using STATA version 17 and standardized mean difference effect sizes were calculated for continuous outcomes and odds ratio for categorical outcomes.

RESULTS

Out of the 90 studies screened for eligibility, 20 RCT studies were included for the systematic review and 15 for the meta-analysis. Close to two-thirds of the studies were from Europe (n = 7) and Asia (n = 6). A combination of educational and behavioral intervention strategies were used for a period ranged from 8 days to 12 months. The pharmacist-led intervention improved adherence to treatment by 4.79 times (AOR = 4.79; 95%CI = 2.64, 8.68; p-value<0.0001), reduced the occurrence of ADEs by 1.28 (SMD = -1.28; 95%CI = -0.04-2.52; p-value = 0.04) and decreased the overall MRPs by 0.53 (SMD = -0.53; 95%CI = -0.79, -0.28; p-value<0.0001) compared to control groups.

CONCLUSION

This study found out that pharmacist-led interventions can significantly lower MRPs among patients treated for cancer. Hence, a global concerted effort has to be made to integrate pharmacists in a multidisciplinary direct cancer care.

Health Literacy-Informed Communication to Reduce Discharge Medication Errors in Hospitalized Children: A Randomized Clinical Trial

Importance

Inadequate communication between caregivers and clinicians at hospital discharge contributes to medication dosing errors in children. Health literacy-informed communication strategies during medication counseling can reduce dosing errors but have not been tested in the pediatric hospital setting.

Objective

To test a health literacy-informed communication intervention to decrease liquid medication dosing errors compared with standard counseling in hospitalized children.

Design, Setting, and Participants

This parallel, randomized clinical trial was performed from June 22, 2021, to August 20, 2022, at a tertiary care, US children's hospital. English- and Spanish-speaking caregivers of hospitalized children 6 years or younger prescribed a new, scheduled liquid medication at discharge were included in the analysis.

Interventions

Permuted block (n = 4) randomization (1:1) to a health literacy-informed discharge medication communication bundle (n = 99) compared with standard counseling (n = 99). A study team member delivered the intervention consisting of a written, pictogram-based medication instruction sheet, teach back (caregivers state information taught), and demonstration of dosing with show back (caregivers show how they would draw the liquid medication in the syringe).

Main Outcome and Measures

Observed dosing errors, assessed using a caregiver-submitted photograph of their child's medication-filled syringe and expressed as the percentage difference from the prescribed dose. Secondary outcomes included caregiver-reported medication knowledge. Outcome measurements were blinded to participant group assignment.

Results

Among 198 caregivers randomized (mean [SD] age, 31.4 [6.5] years; 186 women [93.9%]; 36 [18.2%] Hispanic or Latino and 158 [79.8%] White), the primary outcome was available for 151 (76.3%). The observed mean (SD) percentage dosing error was 1.0% (2.2 percentage points) among the intervention group and 3.3% (5.1 percentage points) among the standard counseling group (absolute difference, 2.3 [95% CI, 1.0-3.6] percentage points; P < .001). Twenty-four of 79 caregivers in the intervention group (30.4%) measured an incorrect dose compared with 39 of 72 (54.2%) in the standard counseling group (P = .003). The intervention enhanced caregiver-reported medication knowledge compared with the standard counseling group for medication dose (71 of 76 [93.4%] vs 55 of 69 [79.7%]; P = .03), duration of administration (65 of 76 [85.5%] vs 49 of 69 [71.0%]; P = .04), and correct reporting of 2 or more medication adverse effects (60 of 76 [78.9%] vs 13 of 69 [18.8%]; P < .001). There were no differences in knowledge of medication name, indication, frequency, or storage.

Conclusions and Relevance

A health literacy-informed discharge medication communication bundle reduced home liquid medication administration errors and enhanced caregiver medication knowledge compared with standard counseling. Routine use of these standardized strategies can promote patient safety following hospital discharge.

Trial Registration

ClinicalTrials.gov Identifier: NCT05143047.

An mHealth Design to Promote Medication Safety in Children with Medical Complexity

BACKGROUND

Children with medical complexity (CMC) are uniquely vulnerable to medication errors and preventable adverse drug events because of their extreme polypharmacy, medical fragility, and reliance on complicated medication schedules and routes managed by undersupported family caregivers. There is an opportunity to improve CMC outcomes by designing health information technologies that support medication administration accuracy, timeliness, and communication within CMC caregiving networks.

OBJECTIVES

The present study engaged family caregivers, secondary caregivers, and clinicians who work with CMC in a codesign process to identify: (1) medication safety challenges experienced by CMC caregivers and (2) design requirements for a mobile health application to improve medication safety for CMC in the home.

METHODS

Study staff recruited family caregivers, secondary caregivers, and clinicians from a children's hospital-based pediatric complex care program to participate in virtual codesign sessions. During sessions, the facilitator-guided codesigners in generating and converging upon medication safety challenges and design requirements. Between sessions, the research team reviewed notes from the session to identify design specifications and modify the prototype. After design sessions concluded, each session recording was reviewed to confirm that all designer comments had been captured.

RESULTS

A total of N = 16 codesigners participated. Analyses yielded 11 challenges to medication safety and 11 corresponding design requirements that fit into three broader challenges: giving the right medication at the right time; communicating with others about medications; and accommodating complex medical routines. Supporting quotations from codesigners and prototype features associated with each design requirement are presented.

CONCLUSION

This study generated design requirements for a tool that may improve medication safety by creating distributed situation awareness within the caregiving network. The next steps are to pilot test tools that integrate these design requirements for usability and feasibility, and to conduct a randomized control trial to determine if use of these tools reduces medication errors.

Perceptions of chemotherapy calendar creation among US pediatric oncologists

BACKGROUND

An effective chemotherapy calendar system between the clinician and the patient/caregiver can improve patient-centered outcomes. There is lack of research on how chemotherapy calendars are created and what aspects are important to pediatric oncology physicians.

PROCEDURE

In an online survey of pediatric oncology physicians, we evaluated institutional practices, perceptions of chemotherapy calendar creation, and desires for future tools. A total of 220 survey participants provided data (10.4% participant response rate) from 123 institutions (53.5% represented institutions).

RESULTS

Participants indicated that 72% always or most of the time their institution provides a chemotherapy calendar, most commonly at the start of a new cycle (90%) or with a dosing change (68%). Factors such as the health literacy of the family, prior nonadherence, type of cancer, and desire of the family affected the creation decision. Advanced practice providers (45%) or nurse coordinator/navigators (43%) were most likely to create the chemotherapy calendar. No significant difference was found between the likelihood of creating a chemotherapy calendar and institutional size (p = .09) or physician years in practice (p = .26). Approximately 95% of participants indicated chemotherapy calendar creation software that improved ease and efficiency would be moderately to extremely useful.

CONCLUSION

Future efforts should focus on co-design of an efficient and effective chemotherapy calendar by engaging with nursing and advanced practice providers along with caregivers of children with cancer.

Measurement of Ambulatory Medication Errors in Children: A Scoping Review

BACKGROUND AND OBJECTIVES

Children use most medications in the ambulatory setting where errors are infrequently intercepted. There is currently no established measure set for ambulatory pediatric medication errors. We have sought to identify the range of existing measures of ambulatory pediatric medication errors, describe the data sources for error measurement, and describe their reliability.

METHODS

We performed a scoping review of the literature published since 1986 using PubMed, CINAHL, PsycINFO, Web of Science, Embase, and Cochrane and of grey literature. Studies were included if they measured ambulatory, including home, medication errors in children 0 to 26 years. Measures were grouped by phase of the medication use pathway and thematically by measure type.

RESULTS

We included 138 published studies and 4 studies from the grey literature and identified 21 measures of medication errors along the medication use pathway. Most measures addressed errors in medication prescribing (n = 6), and administration at home (n = 4), often using prescription-level data and observation, respectively. Measures assessing errors at multiple phases of the medication use pathway (n = 3) frequently used error reporting databases and prospective measurement through direct in-home observation. We identified few measures of dispensing and monitoring errors. Only 31 studies used measurement methods that included an assessment of reliability.

CONCLUSIONS

Although most available, reliable measures are too resource and time-intensive to assess errors at the health system or population level, we were able to identify some measures that may be adopted for continuous measurement and quality improvement.

Unveiling medication errors in liver transplant patients towards enhancing the imperative patient safety

Background

Medication errors (MEs) are a significant healthcare problem that can harm patients and increase healthcare expenses. Being immunocompromised, liver-transplant patients are at high risk for complications if MEs inflict harmful or damaging effects. The present study reviewed and analyzed all MEs reported in Liver Transplant Patients.

Methods

All MEs in the Liver Transplant Patients admitted between January 2016 to August 2022 were retrieved through the computerized physician order entry system, which two expert pharmacists classified according to the type and severity risk index.

Results

A total of 314 records containing 407 MEs were committed by at least 71 physicians. Most of these errors involved drugs unrelated to managing liver-transplant-related issues. Antibiotic prescriptions had the highest mistake rate (17.0%), whereas immunosuppressants, routinely used in liver transplant patients, rank second with fewer than 14% of the identified MEs. The most often reported MEs (43.2%) are type-C errors, which, despite reaching patients, did not cause patient harm. Subgroup analysis revealed several factors associated with a statistically significant great incidence of MEs among physicians treating liver transplant patients.

Conclusion

Although a substantial number of MEs occurred with liver transplant patients, the majority are not related to liver-transplant medications, which mainly belonged to type-C errors. This could be attributed to polypharmacy of transplant patients or the heavy workload on health care practitioners. Improving patient safety requires adopting regulations and strategies to promptly identify MEs and address potential errors.

Improving Pharmacist-Led Pediatric Patient Education on Oral Chemotherapy at Home

Oral chemotherapy (OC) has been increasingly used in pediatric patients diagnosed with cancer, which is primarily managed in the outpatient setting. Different from adults, pediatric patients face unique challenges in administering these hazardous medications at home. Because of the complexity of pediatric pharmaceutical care and the hazardous nature of chemotherapy agents, comprehensive patient education is imperative to mitigate the potential safety risks associated with OC administration at home. Pharmacists play a vital role in patient education and medication consultations. However, the lack of practice guidelines and limited resources supporting OC counseling are noted. Additional barriers include insufficient knowledge and training on OC, which can be improved by continuing education. In a regional children's hospital, a comprehensive OC education checklist was developed for pediatric patients and their caregivers to standardize consultations led by pharmacists. An infographic OC handout was also formulated to improve patient knowledge and awareness. Moreover, innovative approaches such as using telepharmacy, smartphone applications, and artificial intelligence have been increasingly integrated into patient care, which can help optimize OC consultations for children and adolescents. Further studies are warranted to enhance oral chemotherapy education specifically tailored for pediatric patients in outpatient settings.

Medication errors in an oncology inpatient setting in India-Audit by clinical pharmacists

BACKGROUND

Good clinical practices and strict vigilance are needed, especially for patients receiving chemotherapy. Regular audits using a specially developed tool need to be conducted in the oncology wards to identify lapses in the use of chemotherapy drugs.

METHODOLOGY

Observational study was conducted in the adult and paediatric oncology inpatient settings in an Indian tertiary care hospital for a period of 2.5 years. It was an audit of case files of chemotherapy patients for their drug prescriptions, medication reconciliation records and adverse drug reports. Data was presented as frequencies and percentages.

RESULTS

1.3% medication errors and 0.23% adverse drug reactions were reported during the study period. Majority were transcription (38%) and drug reconstitution errors (29%) and were either in the near-miss or no-harm category.

CONCLUSION

Medication errors were found in the oncology wards, but due to the vigilance of clinical pharmacists, none of the patients were harmed as a consequence of these errors.

Clinical and economic impact of clinical oncology pharmacy in cancer patients receiving injectable anticancer treatments: a systematic review

PURPOSE

Clinical pharmacy can reduce drug-related iatrogenesis by improving the management of adverse effects of drugs, limiting drug-drug interactions, and improving patient adherence. Given the vulnerability of cancer patients and the toxicity of injectable anticancer drugs, clinical pharmacy service (CPS) could provide a significant clinical benefit in cancer care. This review aims to synthesize existing evidence on clinical pharmacy's impact on patients treated with intravenous anticancer drugs.

METHODS

A comprehensive search was performed in the PubMed/Medline database from January 2000 to December 2021, associating the keywords: clinical pharmacy, pharmaceutical care, pharmacist, oncology, and chemotherapy. To be eligible for inclusion, studies have to report clinical pharmaceutical services for patients treated with intravenous chemotherapy with a clinical and/or economic impact.

RESULTS

Forty-one studies met the selection criteria. Various CPS were reported: medication reconciliation, medication review, and pharmaceutical interview with patient. There was a lack of randomized study (n = 3; 7.3%). In one randomized controlled trial, pharmaceutical intervention significantly improved quality of life of patients receiving pharmaceutical care during injectable anticancer drugs courses. Economical results appear to show positive impact of clinical pharmacy with cost savings reported from 3112.87$ to 249 844€. Although most studies were non-comparative, they highlighted that clinical pharmacy tend to limit chemotherapy side effects and drug-related problems, improve quality of life and satisfaction of patients and healthcare professional, and a positive economic impact.

CONCLUSION

Clinical pharmacy can reduce adverse drug events in cancer patients. More robust and economic evaluations are still required to support its development in everyday practice.

Safer Type 1 Diabetes Care at Home: SEIPS-based Process Mapping with Parents and Clinicians

Introduction

The limited data indicate that pediatric medical errors in the outpatient setting, including at home, are common. This study is the first step of our Ambulatory Pediatric Patient Safety Learning Lab to address medication errors and treatment delays among children with T1D in the outpatient setting. We aimed to identify failures and potential solutions associated with medication errors and treatment delays among outpatient children with T1D.

Methods

A transdisciplinary team of parents, safety researchers, and clinicians used Systems Engineering Initiative for Patient Safety (SEIPS) based process mapping of data we collected through in-home medication review, observation of administration, chart reviews, parent surveys, and failure modes and effects analysis (FMEA).

Results

Eight (57%) of the 14 children who had home visits experienced 18 errors (31 per 100 medications). Four errors in two children resulted in harm, and 13 had the potential for harm. Two injuries occurred when parents failed to treat severe hypoglycemia and lethargy, and two were due to repeated failures to administer insulin at home properly. In SEIPS-based process maps, high-risk errors occurred during communication between the clinic and home or in management at home. Two FMEAs identified interventions to better communicate with families and support home care, especially during evolving illness.

Conclusion

Using SEIPS-based process maps informed by multimodal methods to identify medication errors and treatment delays, we found errors were common. Better support for managing acute illness at home and improved communication between the clinic and home are potentially high-yield interventions.

Risk management patterns in radiation oncology-results of a national survey within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project

PURPOSE

Risk management (RM) is a key component of patient safety in radiation oncology (RO). We investigated current approaches on RM in German RO within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project. Aim was not only to evaluate a status quo of RM purposes but furthermore to discover challenges for sustainable RM that should be addressed in future research and recommendations.

METHODS

An online survey was conducted from June to August 2021, consisting of 18 items on prospective and reactive RM, protagonists of RM, and self-assessment concerning RM. The survey was designed using LimeSurvey and invitations were sent by e‑mail. Answers were requested once per institution.

RESULTS

In all, 48 completed questionnaires from university hospitals, general and non-academic hospitals, and private practices were received and considered for evaluation. Prospective and reactive RM was commonly conducted within interprofessional teams; 88% of all institutions performed prospective risk analyses. Most institutions (71%) reported incidents or near-events using multiple reporting systems. Results were presented to the team in 71% for prospective analyses and 85% for analyses of incidents. Risk conferences take place in 46% of institutions. 42% nominated a manager/committee for RM. Knowledge concerning RM was mostly rated "satisfying" (44%). However, 65% of all institutions require more information about RM by professional societies.

CONCLUSION

Our results revealed heterogeneous patterns of RM in RO departments, although most departments adhered to common recommendations. Identified mismatches between recommendations and implementation of RM provide baseline data for future research and support definition of teaching content.

Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: A multisite longitudinal assessment

BACKGROUND

There is little longitudinal information about the type and frequency of harm resulting from medication errors among outpatient children with cancer. We aimed to characterize rates and types of medication errors and harm to outpatient children with leukemia and lymphoma over 7 months of treatment.

METHODS

We recruited children taking medications at home for leukemia or lymphoma from three pediatric cancer centers. Errors were identified by chart review, in-home medication review, observation of administration, and interviews. Physician reviewers confirmed error (Fleiss' κ = 0.95), harm (Fleiss' κ = 0.82), and suggested interventions. Generalized linear mixed models with random effects were used to account for clustering by site.

RESULTS

Among 131 children taking 1669 medications with 367 home visits, 408 errors were identified, including 242 with potential for harm and 39 with harm (1.0 harm per 1000 patient-days [95% CI, 0.1-9.8]). Ten percent of children were injured by errors and 42% had errors with potential for harm. Twenty-six percent of caregivers reported that miscommunication led to missed doses or overdoses at home. Children on >13 medications had significantly more serious medication errors than those on fewer medications (77% vs 61%; p = .05). Physician reviewers judged that improved communication among caregivers and between caregivers and clinicians may have prevented the most harm (66%).

CONCLUSIONS

In this longitudinal study, 10% children with leukemia or lymphoma experienced adverse drug events because of outpatient medication errors. Improvements addressing communication with and among caregivers should be codeveloped with families and based on human-factors engineering.

PLAIN LANGUAGE SUMMARY

In this longitudinal study, medication errors in the clinic, pharmacy, or at home among children with leukemia or lymphoma over a 7-month period were common, and 10% suffered harm because of errors. Children on >13 medications had significantly more serious medication errors than those on fewer medications (77% vs 61%; p = .05). Physician reviewers judged that improved communication among caregivers and between caregivers and clinicians may have prevented the most harm (66%). Improvements addressing communication with and among caregivers should be codeveloped with families and based on human-factors engineering.

Application of the Failure Mode and Effects Analysis (FMEA) to identify vulnerabilities and opportunities for improvement prior to implementing a computerized prescription order entry (CPOE) system in a university hospital oncology clinic

INTRODUCTION

Prior to implementing a new computerized prescription order entry (CPOE) application, the potential risks associated with this system were assessed and compared to those of paper-based prescriptions. The goal of this study is to identify the vulnerabilities of the CPOE process in order to adapt its design and prevent these potential risks.

METHODS AND MATERIALS

Failure mode and effects analysis (FMEA) was used as a prospective risk-management technique to evaluate the chemotherapy medication process in a university hospital oncology clinic. A multidisciplinary team assessed the process and compared the critical steps of a newly developed CPOE application versus paper-based prescriptions. The potential severity, occurrence and detectability were assessed prior to the implementation of the CPOE application in the clinical setting.

RESULTS

The FMEA led to the identification of 24 process steps that could theoretically be vulnerable, therefore called failure modes. These failure modes were grouped into four categories of potential risk factors: prescription writing, patient scheduling, treatment dispensing and patient follow-up. Criticality scores were calculated and compared for both strategies. Three failure modes were prioritized and led to modification of the CPOE design. Overall, the CPOE pathway showed a potential risk reduction of 51% compared to paper-based prescriptions.

CONCLUSION

FMEA was found to be a useful approach to identify potential risks in the chemotherapy medication process using either CPOE or paper-based prescriptions. The e-prescription mode was estimated to result in less risk than the traditional paper mode.

Development and use of an innovative Gap Finding Tool to create a Pharmaceutical Care Model within a paediatric oncology setting

INTRODUCTION

A paediatric cancer ward is a setting where pharmacists participate in direct patient care, acting as coordinators between the patient, caregivers and healthcare professionals. The aim of the study was to develop a Gap Finding Tool to support the setting up of a pharmaceutical care model at a Paediatric-Adolescent Cancer Ward.

METHODS

The Standards of Practice for Clinical Pharmacy Services by the Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Clinical Pharmacy (2013), the American College of Clinical Pharmacy (2014) and the European Association of Hospital Pharmacists (2014) were used to compile the Gap Finding Tool. The developed Tool was tested for content validity by a panel of experts and subsequently implemented over 2 months.

RESULTS

The Gap Finding Tool comprised of nine sections with an average of eight statements each about pharmacy services that should be provided at ward level. For each statement, the rater indicates whether these contributions are provided. When the Tool was implemented at the Paediatric-Adolescent Cancer Ward, four major gaps were identified, namely, absence of a clinical pharmacist, lack of medicines information, vetting of chemotherapy prescriptions by pharmacist with limited access to patient data and lack of pharmacist-input on medicines availability. Processes requiring optimisation included discharge medication advice and documentation processes.

CONCLUSION

The developed Gap Finding Tool is an innovative tool which is versatile and can be used in ward or ambulatory clinical settings to identify gaps in pharmaceutical processes and services and compare national or regional practices to international standards.

Team-Based Care for Cancer Survivors With Comorbidities: A Systematic Review

Coordination of quality care for the growing population of cancer survivors with comorbidities remains poorly understood, especially among health disparity populations who are more likely to have comorbidities at the time of cancer diagnosis. This systematic review synthesized the literature from 2000 to 2022 on team-based care for cancer survivors with comorbidities and assessed team-based care conceptualization, teamwork processes, and outcomes. Six databases were searched for original articles on adults with cancer and comorbidity, which defined care team composition and comparison group, and assessed clinical or teamwork processes or outcomes. We identified 1,821 articles of which 13 met the inclusion criteria. Most studies occurred during active cancer treatment and nine focused on depression management. Four studies focused on Hispanic or Black cancer survivors and one recruited rural residents. The conceptualization of team-based care varied across articles. Teamwork processes were not explicitly measured, but teamwork concepts such as communication and mental models were mentioned. Despite team-based care being a cornerstone of quality cancer care, studies that simultaneously assessed care delivery and outcomes for cancer and comorbidities were largely absent. Improving care coordination will be key to addressing disparities and promoting health equity for cancer survivors with comorbidities.

Incidence, severity, and preventability of adverse events during the induction of patients with acute lymphoblastic leukemia in a tertiary care pediatric hospital in Mexico

Healthcare-associated adverse events represent a heavy burden of symptoms for pediatric oncology patients. Their description allows knowing the safety and quality of the care processes in countries with limited resources. This study aimed to describe the incidence, types, severity, and preventability of adverse events occurring in pediatric patients with acute lymphoblastic leukemia during the induction phase in a tertiary care pediatric hospital in Mexico. This study analyzed a cohort based on medical records of between 2015 and 2017. Initially, information on patients and adverse events was collected; subsequently, two pediatric oncologist reviewers independently classified adverse events, severity and preventability. Agreement between reviewers was evaluated. Adverse events incidence rates were estimated by type, severity, and preventability. One-hundred and eighty-one pediatric patients pediatric patients with acute lymphoblastic leukemia were studied. An overall adverse events rate of 51.8 per 1000 patient-days was estimated, involving 81.2% of patients during induction. Most adverse events were severe or higher (52.6%). Infectious processes were the most common severe or higher adverse event (30.5%). The presence of adverse events caused 80.2% of hospital readmissions. Of the adverse events, 10.5% were considered preventable and 53.6% could be ameliorable in severity. Improving the safety and quality of the care processes of children with acute lymphoblastic leukemia is possible, and this should contribute to the mitigation and prevention of adverse events associated morbidity and mortality during the remission induction phase.

Risk Factors for Adverse Events in Patients With Breast, Colorectal, and Lung Cancer

OBJECTIVE

The aim of the study was to identify risk factors associated with medical errors and iatrogenic injuries during an initial course of cancer-directed treatment.

METHODS

In this retrospective cohort study of 400 patients 18 years or older undergoing an initial course of treatment for breast, colorectal, or lung cancer at a comprehensive cancer center, we abstracted patient, disease, and treatment-related variables from the electronic medical record. We examined adverse events (AEs) and preventable AEs by risk factor using the χ2 or Fisher exact tests. We estimated the association between risk factors and the relative risk of an additional AE or preventable AE in multivariable negative binomial regression models with backwards selection (P < 0.1).

RESULTS

There were 304 AEs affecting 136 patients (34%) and 97 preventable AEs affecting 53 patients (13%). In multivariable analyses, AEs were overrepresented in those with lung cancer compared with patients with breast cancer (incident rate ratio = 1.9, 95% confidence interval = 1.1-3.2). Nonwhite race (1.6, 1.0-2.6), Hispanic or Latino ethnicity (2.0, 0.9-4.1), advanced disease (1.7, 1.1-2.6), use of each additional class of high-risk nonchemotherapy medication (1.6, 1.3-1.9), and chemotherapy (2.1, 1.3-3.3) were all associated with risk of an additional AE. Preventable AEs were associated with lung cancer (7.4, 2.4-23.2), Hispanic or Latino ethnicity (5.5, 1.7-17.9), and high-risk nonchemotherapy medications (1.5, 1.2-2.0).

CONCLUSIONS

Risk factors for AEs among patients with cancer reflected patients' underlying disease, cancer-directed therapy, and high-risk noncancer medications. The association of AEs with ethnicity merits further research. Risk factor models could be used prospectively to identify patients with cancer at increased risk of harm.

Preventing Home Medication Administration Errors

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Error Detection and Cost Savings With an Image-Based Workflow Management System Connected to a Computerized Prescription Order Entry Program for Antineoplastic Compounding

OBJECTIVE

The aim of the study was to analyze both the prevalence of errors with the implementation of an image-based workflow management system during the antineoplastic compounding process, and the estimated costs associated with the negative clinical outcome if the errors had not been intercepted.

METHODS

Three months after the implementation of Phocus Rx system at a hospital pharmacy department, the identification, classification (type, preparation stage, and cause), and potential severity degree (from negligible to catastrophic) of the errors intercepted were determined. The probability of an error causing an adverse event if it had reached the patient (from nil [0] to high [0.6]) and its consequences was estimated by a team of clinical pharmacists and physicians. Cost-effectiveness analysis from the hospital's perspective was performed.

RESULTS

Overall, 9872 antineoplastic medications were prepared using Phocus Rx. The total compounding error rate was 0.8% (n = 78, 56 [69.2%] were related to incorrect dose, 20 [28.2%] to incorrect drug preparation or conditioning technique, and 2 [2.6%] were wrong drugs). Approximately 70% of the detected errors were classified as undetectable via the previous verification practice, with 11.55% judged to be potentially severe (n = 9) and 51.3% moderate (n = 29). Likelihood of occurrence of an adverse event was medium (0.4) to high (0.6) for 37.2% of the errors. Estimated cost ratio and return on investment were €4.21 and 321%, respectively.

CONCLUSIONS

The implementation of Phocus Rx prevented antineoplastic preparation errors that would have reached the patient otherwise. In addition, acquisition of this technology was estimated to be cost-effective.

Testing the Use of Data Drawn from the Electronic Health Record to Compare Quality

Introduction

Health systems spend $1.5 billion annually reporting data on quality, but efficacy and utility for benchmarking are limited due, in part, to limitations of data sources. Our objective was to implement and evaluate measures of pediatric quality for three conditions using electronic health record (EHR)-derived data.

Methods

PCORnet networks standardized EHR-derived data to a common data model. In 13 health systems from 2 networks for 2015, we implemented the National Quality Forum measures: % children with sickle cell anemia who received a transcranial Doppler; % children on antipsychotics who had metabolic screening; and % pediatric acute otitis media with amoxicillin prescribed. Manual chart review assessed measure accuracy.

Results

Only 39% (N = 2,923) of 7,278 children on antipsychotics received metabolic screening (range: 20%-54%). If the measure indicated screening was performed, the chart agreed 88% of the time [95% confidence interval (CI): 81%-94%]; if it indicated screening was not done, the chart agreed 86% (95% CI: 78%-93%). Only 69% (N = 793) of 1,144 children received transcranial Doppler screening (range across sites: 49%-88%). If the measure indicated screening was performed, the chart agreed 98% of the time (95% CI: 94%-100%); if it indicated screening was not performed, the chart agreed 89% (95% CI: 82%-95%). For acute otitis media, chart review identified many qualifying cases missed by the National Quality Forum measure, which excluded a common diagnostic code.

Conclusions

Measures of healthcare quality developed using EHR-derived data were valid and identified wide variation among network sites. This data can facilitate the identification and spread of best practices.

Medication Errors During Treatment with New Oral Anticancer Agents: Consequences for Clinical Practice Based on the AMBORA Study

Patients treated with oral anticancer agents (e.g., kinase inhibitors) are a high-risk population for medication errors due to, for example, polymedication, age, and limited adherence. Systematic evaluations regarding frequencies and causes of medication errors and resulting harm are lacking. Our previously published multicenter randomized AMBORA trial revealed that an intensified support by clinical pharmacologists/pharmacists for patients and the treatment team considerably reduced drug-related problems and improved patient-reported outcomes. Using this database, we performed a comprehensive, additional analysis focusing on medication errors related to the patients' complete medication with consideration of the antitumor agents, concomitantly administered drugs, and herb/food intake. Two hundred two patients starting a new oral anticancer drug regardless of the tumor entity were included. Clinical pharmacologists/pharmacists performed advanced medication reviews for 12 weeks. Medication errors were characterized regarding type, cause, patient harm, and the involved medicines. We detected 1.7 medication errors per patient (335/202). Of the medication errors (216/335), 64.5% occurred within the concomitant medication. Patients caused 28.4% of the medication errors. There were 67.8% detected immediately after the start of the new oral regimen, and 14.9% resulted in temporary harm. Drug-drug or drug-food interactions accounted for 24.8% of the medication errors. Patients and physicians need to be addressed in strategies for systematic reduction of medication errors during treatment with new oral antitumor drugs. Clinical decision support systems focusing on drug-drug interactions capture only a minority of the medication errors. Specialists with expertise in clinical pharmacology/pharmacy should support both the treating physicians as well as the patients for improved patient safety.

Prevalence of Medication Errors and the Associated Factors: A Prospective Observational Study Among Cancer Patients at Mbarara Regional Referral Hospital

BACKGROUND

Medication error is one of the most common medical errors in the practice of modern medicine. Among cancer patients receiving chemotherapy, medication errors can be potentially harmful given the narrow therapeutic index, complex dosing, and toxic nature of anti-cancer drugs.

OBJECTIVE

This study aimed to determine the incidence and factors associated with medication errors among cancer patients.

METHODS

The study was a prospective observational study carried out at the cancer unit of Mbarara Regional Referral Hospital, Southwestern Uganda. The study included 110 participants, both adults and children receiving chemotherapy. The study was carried out for a period of five months from January to May 2020. A checklist was used to collect patient, medication, and disease information to identify the prescription, transcription, dispensing, and administration errors.

RESULTS

Of the 110 participants, 52 (47.3%) experienced a total of 78 medication errors (MEs). Of these, 33 (42.31%) were prescription errors, 29 (37.18%) administration errors, 9 (11.54%) transcription errors, and 7 (8.97%) dispensing errors. In the adjusted logistic regression of factors associated with medication errors, urban residents (aOR, 4.59; 95% CI, 1.08, 19.53, p= 0.039) and educated participants (at secondary level) (aOR, 10.51; 95% CI, 1.43, 77.14, p= 0.021) had a significantly higher risk of experiencing medication errors. Participants treated with alkylating agents (aOR, 2.87; 95% CI, 1.07, 7.72, p= 0.036) had a greater risk of experiencing medication errors when compared to other classes of chemotherapy.

CONCLUSION

The incidence of medication errors among cancer patients was high in Mbarara Regional Referral Hospital. Prescription errors were the most common type of error followed by administration errors, and dispensing errors were the least common. Residence, education level, and alkylating agent chemotherapy were significantly associated with occurrence of medication errors.

The Anatomy and Physiology of Teaming in Cancer Care Delivery: A Conceptual Framework

Care coordination challenges for patients with cancer continue to grow as expanding treatment options, multimodality treatment regimens, and an aging population with comorbid conditions intensify demands for multidisciplinary cancer care. Effective teamwork is a critical yet understudied cornerstone of coordinated cancer care delivery. For example, comprehensive lung cancer care involves a clinical "team of teams"-or clinical multiteam system (MTS)-coordinating decisions and care across specialties, providers, and settings. The teamwork processes within and between these teams lay the foundation for coordinated care. Although the need to work as a team and coordinate across disciplinary, organizational, and geographic boundaries increases, evidence identifying and improving the teamwork processes underlying care coordination and delivery among the multiple teams involved remains sparse. This commentary synthesizes MTS structure characteristics and teamwork processes into a conceptual framework called the cancer MTS framework to advance future cancer care delivery research addressing evidence gaps in care coordination. Included constructs were identified from published frameworks, discussions at the 2016 National Cancer Institute-American Society of Clinical Oncology Teams in Cancer Care Workshop, and expert input. A case example in lung cancer provided practical grounding for framework refinement. The cancer MTS framework identifies team structure variables and teamwork processes affecting cancer care delivery, related outcomes, and contextual variables hypothesized to influence coordination within and between the multiple clinical teams involved. We discuss how the framework might be used to identify care delivery research gaps, develop hypothesis-driven research examining clinical team functioning, and support conceptual coherence across studies examining teamwork and care coordination and their impact on cancer outcomes.

Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy

INTRODUCTION

To describe pharmacist interventions as a result of an independent double check during cognitive order verification of outpatient parenteral anti-cancer therapy.

METHODS

A single-center, retrospective analysis of all individual orders for outpatient, parenteral anti-cancer agents within a hematology/oncology infusion center during a 30 day period was conducted. The primary endpoint was error identification rates during first and second verification. Secondary endpoints included the type, frequency, and severity of errors identified during second verification using a modified National Coordinating Council for Medication Error Reporting and Prevention Index.

RESULTS

A total of 1970 anti-cancer parenteral orders were screened, from which 1645 received an independent double check and were included. The number of errors identified during first and second verification were 30 (1.8%) and 10 (0.6%) respectively; second verification resulted in a 33.3% increase in corrected errors. The 10 errors identified during second verification included: four rate transcriptions to optimize pump interoperability, three rate and/or volume modifications, two dosage adjustments, and one treatment deferral due to toxicity. The severity was classified as Category A for four (40%), Category C for three (30%), and Category D for three (30%) errors. This correlated to a low capacity for harm for seven (70%) and a serious capacity for three (30%) errors.

CONCLUSIONS

Second verification of outpatient, parenteral anti-cancer medication orders resulted in a 33.3% increase in corrected errors. Three errors detected during second verification were determined to have a serious capacity for harm, supporting the value of independent double checks during pharmacist cognitive order verification.

Patients and relatives as auditors of safe practices in oncology and hematology day hospitals

BACKGROUND

When there is a gap in professionals' adherence to safe practices during cancer treatment, the consequences can be serious. Identifying these gaps in order to enable improvements in patient safety can be a challenge. This study aimed to assess if cancer patients and their relatives can be given the skills to audit reliably four safe practices, and to explore whether they are willing to play this new role.

METHODS

We recruited 136 participants in 2018, from the oncology and haematology day hospital of a tertiary hospital in Spain. Patient identification, hand hygiene, blood or chemotherapy identification, and side effects related to transfusion and chemotherapy, were the safe practices selected for evaluation. The study comprised two parts: an interventional educational program and a cross-sectional design to collect data and assess to what degree participants are able and willing to be auditors depending on their characteristics using multivariate logistic regression models. A participant's auditing skill were assessed pre and post the educational intervention.

RESULTS

The model was seeking predictors of being a good auditor. 63 participants (46.3%) were classified as good auditors after the training. To have younger age, higher educational level and to have had an experience of an adverse event were associated with a higher probability of being a good auditor. Additionally, 106 (77.9%) participants said that they would like to audit anonymously the professionals' compliance of at least three of four safe practices. The willingness to audit safe practices differed depending on the safe practice but these differences did not reach statistical significance.

CONCLUSIONS

The data gathered by patients and relatives acting as auditors can provide healthcare organizations with valuable information about safety and quality of care that is not accessible otherwise. This new role provides an innovative way to engage patients and their families' in healthcare safety where other methods have not had success. The paper sets out the methods that healthcare organizations need to undertake to enrol and train patients and relatives in an auditor role.

Enabling sustained communication with patients for safe and effective management of oral chemotherapy: A longitudinal ethnography

AIMS

To examine how patients received, understood, and acted on healthcare professional communication about their oral chemotherapeutic regimen throughout their treatment.

DESIGN

A longitudinal ethnographic study.

METHODS

Over 60 hr of observational data were recorded, in the form of field notes and audio-recordings from interactions among nine oncology doctors, six oncology nurses, eight patients, and 11 family members over a period of 6 months in outpatient departments in one hospital in Northern Ireland. Sixteen semi-structured interviews with patients and three focus groups with healthcare professionals were also carried out. This study took place from October 2013-June 2016. Data were thematically analysed.

RESULTS

Three themes where identified from the data. These were initiating concordance through first communication about oral chemotherapy; which focused on initial communication during oncology consultations about oral chemotherapy, sustained communication of managing chemotherapy side effects; which was about how communication processes supported timely and effective side effect management and un-sustained communication of oral chemotherapy medication-taking practice; when patients and healthcare professionals failed to communicate effectively about chemotherapy medication-taking.

CONCLUSION

The two most important factors in ensuring the optimal management of oral chemotherapeutic medicines are early recognition and appropriate response to side effects and the maintenance of safe and effective medication administration. This study found that oncology doctors and nurses engaged in sustained communication about the side effects of chemotherapy but did not focus their communication on safe administration after the first consultation.

IMPACT

Based on this evidence, we recommend that healthcare professionals who provide oral chemotherapy for home administration should review their processes and procedures. Healthcare professionals need to ensure that they embed frequent communication for the duration of treatment between themselves and patients, including open discussion and advice, about side effects and medication administration.

Effect of a Mobile App for the Pharmacotherapeutic Follow-Up of Patients With Cancer on Their Health Outcomes: Quasi-Experimental Study

Background

Oral antineoplastic agents (OAAs) have revolutionized cancer management. However, they have been reported with adverse side effects and drug-drug interactions. Moreover, patient adherence to OAA treatment is critical. Mobile apps can enable remote and real-time pharmacotherapeutic monitoring of patients, while also promoting patient autonomy in their health care.

Objective

The primary objective was to analyze the effect of using a mobile app for the follow-up of patients with oncohematological malignancies undergoing treatment with OAAs on their health outcomes. The secondary objectives were to analyze the role of the app in communication with health care professionals and patient satisfaction with the app.

Methods

We performed a comparative, quasi-experimental study based on a prepost intervention with 101 patients (control group, n=51, traditional pharmacotherapeutic follow-up vs intervention group, n=50, follow-up through e-OncoSalud, a custom-designed app that promotes follow-up at home and the safety of patients receiving OAAs). The effect of this app on drug safety, adherence to treatment, and quality of life was evaluated.

Results

With regard to drug safety, 73% (37/51) of the patients in the control group and 70% (35/50) of the patients in the intervention group (P=.01) presented with drug-related problems. The probability of detecting an insufficiently treated health problem in the intervention group was significantly higher than that in the control group (P=.04). The proportion of patients who presented with side effects in the intervention group was significantly lower than that in the control group (P>.99). In the control group, 49% (25/51) of the patients consumed some health resources during the first 6 months of treatment compared with 36% (18/50) of the patients in the intervention group (P=.76). Adherence to treatment was 97.6% (SD 7.9) in the intervention group, which was significantly higher than that in the control group (92.9% [SD 10.0]; P=.02). The EuroQol-5D in the intervention group yielded a mean (SD) index of 0.875 (0.156), which was significantly higher than that in the control group (0.741 [0.177]; P<.001). Approximately 60% (29/50) of the patients used the messaging module to communicate with pharmacists. The most frequent types of messages were acknowledgments (77/283, 27.2%), doubts about contraindications and interactions with OAAs (70/283, 24.7%), and consultations for adverse reactions to treatment (39/283, 13.8%). The satisfaction with the app survey conducted in the intervention group yielded an overall mean (SD) score of 9.1 (0.4) out of 10.

Conclusions

Use of e-OncoSalud for the real-time follow-up of patients receiving OAAs facilitated the optimization of some health outcomes. The intervention group had significantly higher health-related quality of life and adherence to treatment than the control group. Further, the probability of the intervention group presenting with side effects was significantly lower than that of the control group.

Thirteen-year analyses of medical oncology outpatient day clinic data: a changing field

Background

Novel treatment modalities like targeted therapy and immunotherapy are currently changing treatment strategies and protocols in the field of medical oncology.

Methods

Numbers of patients and patient contacts admitted to medical oncology day clinics of a large European academic cancer centre in the period from 2006 to 2018 were analysed using our patient administration system.

Results

A patient cohort of 9.870 consecutive individual patients with 125.679 patient contacts was descriptively and retrospectively characterised. Mean age was 59.9 years. A substantial increase in both individual patients treated per year (+45.4%; 2006: 1.100; 2018: 1.599) and annual patient contacts (+63.3%; 2006: 8.857; 2018: 14.467) between 2006 and 2018 was detected. Hence and most interestingly, the ratio of visits per patient increased by approximately one visit per patient per year over the last 12 years (+12.4%; 2006: 8.0; 2018: 9.0). Further, a decrease of patient contacts in more prevalent entities like breast cancer was found, while contacts for orphan diseases like myeloma and sarcoma increased substantially. Interestingly, female patients showed more per patient contacts as compared with men (13.5 vs 11.9). Lastly, short-term safety data of outpatient day clinic admissions are reported.

Conclusions

We present a representative and large set of patient contacts over time that indicates an increasing load in routine clinical work of outpatient cancer care. Increases observed were highest for orphan diseases, likely attributed to centralisation effects and increased treatment complexity.

Disclosure of medical errors: physicians' knowledge, attitudes and practices (KAP) in an oncology center

Background

Between the need for transparency in healthcare, widely promoted by patient’s safety campaigns, and the fear of negative consequences and malpractice threats, physicians face challenging decisions on whether or not disclosing medical errors to patients and families is a valid option.

We aim to assess the knowledge, attitudes and practices (KAP) of physicians in our center regarding medical error disclosure.

Methods

This is a cross-sectional self-administered questionnaire study. The questionnaire was piloted and no major modifications were made.

A day-long training workshop consisting of didactic lectures, short and long case scenarios with role playing and feedback from the instructors, were conducted. Physicians who attended these training workshops were invited to complete the questionnaire at the end of the training, and physicians who did not attend any training were sent a copy of the questionnaire to their offices to complete. To assure anonymity and transparency of responses, we did not query names or departments.

Descriptive statistics were used to present demographics and KAP. The differences between response\s of physicians who received the training and those who did not were analyzed with t-test and descriptive statistics. The 0.05 level of significance was used as a cutoff measure for statistical significance.

Results

Eighty-eight physicians completed the questionnaire (55 attended training (62.50%), and 33 did not (37.50%)). Sixty Five percent of physicians were males and the mean number of years of experience was 16.5 years. Eighty-Seven percent (n = 73) of physicians were more likely to report major harm, compared to minor harm or no harm. Physicians who attended the workshop were more knowledgeable of articles of Jordan’s Law on Medical and Health Liability (66.7% vs 45.5%, p-value = 0.017) and the Law was more likely to affect their decision on error disclosure (61.8% vs 36.4%, p-value = 0.024).

Conclusion

Formal training workshops on disclosing medical errors have the power to positively influence physicians’ KAP toward disclosing medical errors to patients and possibly promoting a culture of transparency in the health care system.

"Iatrogenic Medication Errors reported to the Victorian Poisons Information Centre"

BACKGROUND

Iatrogenic medication errors are a cause of medical morbidity and mortality. They result in significant cost to the Australian healthcare system each year. There is limited Australian evidence describing the iatrogenic errors occurring within the hospital system.

AIMS

To examine and describe iatrogenic medication errors occurring in Victorian healthcare settings through analysis of referrals to a state Poisons Information Centre (PIC).

METHODS

A retrospective review of iatrogenic medication errors reported to the Victorian PIC from community and hospital healthcare settings from January 2015-December 2019.

RESULTS

Over a five year period, 357 iatrogenic errors were identified, 63% (n = 224) of which occurred in a hospital setting. The remaining errors occurred in a community healthcare setting. One in five patients were symptomatic from the medication error at the time of the call to the VPIC, and a change in management was required in 45% (n = 165) of all cases. 5% (n = 17) of patients developed moderate to severe clinical toxicity as determined by the recorded PSS, and 88% (n = 18) of these required critical care management. Incorrect medication dosing accounted for 62% (n = 221) of errors. Common medication dosing errors included: double dose (51%, n = 114), incorrect medication administered (14%, n = 49), incorrect route (9%, n = 31), incorrect patient (6%, n = 22) and adult dose given to a child (4%, n = 15).

CONCLUSIONS

Iatrogenic errors are occurring in the Victorian health care system. These errors can result in serious morbidity. Identification of causative factors and investment in preventative strategies will likely reduce associated morbidity and healthcare costs. This article is protected by copyright. All rights reserved.

Association between cancer-specific adverse event triggers and mortality: A validation study

Background

As there are few validated measures of patient safety in clinical oncology, creating an efficient measurement instrument would create significant value. Accordingly, we sought to assess the validity of a novel patient safety measure by examining the association of oncology‐specific triggers and mortality using administrative claims data.

Methods

We examined a retrospective cohort of 322 887 adult cancer patients enrolled in commercial or Medicare Advantage products for one year after an initial diagnosis of breast, colorectal, lung, or prostate cancer in 2008‐2014. We used diagnosis and procedure codes to calculate the prevalence of 16 cancer‐specific "triggers"–events that signify a potential adverse event. We compared one‐year mortality rates among patients with and without triggers by cancer type and metastatic status using logistic regression models.

Results

Trigger events affected 19% of patients and were most common among patients with metastatic colorectal (41%) and lung (50%) cancers. There was increased one‐year mortality among patients with triggers compared to patients without triggers across all cancer types in unadjusted and multivariate analyses. The increased mortality rate among patients with trigger events was particularly striking for nonmetastatic prostate cancer (1.3% vs 7.5%, adjusted odds ratio 1.96 [95% CI 1.49‐2.57]) and nonmetastatic colorectal cancer (4.1% vs 11.7%, 1.44 [1.19‐1.75]).

Conclusions

The association between adverse event triggers and poor survival among a cohort of cancer patients supports the validity of a cancer‐specific, administrative claims‐based trigger tool.

Clinical and economic impact of medication reconciliation in cancer patients: a systematic review

PURPOSE

Medication reconciliation can reduce drug-related iatrogenesis by facilitating exhaustive information transmission at care transition points. Given the vulnerability of cancer patients to adverse drug events, medication reconciliation could provide a significant clinical benefit in cancer care. This review aims to synthesize existing evidence on medication reconciliation in cancer patients.

METHODS

A comprehensive search was performed in the PubMed/Medline, Scopus, and Web of Science databases, associating the keywords "medication reconciliation" and "cancer" or "oncology."

RESULTS

Fourteen studies met the selection criteria. Various medication reconciliation practices were reported: performed at admission or discharge, for hospitalized or ambulatory patients treated with oral or parenteral anticancer drugs. In one randomized controlled trial, medication reconciliation decreased clinically significant medication errors by 26%. Although most studies were non-comparative, they highlighted that medication reconciliation led to identification of discrepancies and other drug-related problems in up to 88% and 94.7% of patients, respectively. The impact on post-discharge healthcare utilization remains under-evaluated and mostly inconclusive, despite a trend toward reduction. No comparative economic evaluations were available but one study estimated the benefit:cost ratio of medication reconciliation to be 2.31:1, suggesting its benefits largely outweigh its costs. Several studies also underlined the extended pharmacist time required for the intervention, highlighting the need for further cost analysis.

CONCLUSION

Medication reconciliation can reduce adverse drug events in cancer patients. More robust and economic evaluations are still required to support its development in everyday practice.

Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management system on cancer patients' safety

A failure modes, effects and criticality analysis was supported by an observational medication error rate study to analyze the impact of Phocus Rx^®, a new image-based workflow software system, on chemotherapy compounding error rates. Residual risks that should be a target for additional action were identified and prioritized and pharmacy staff satisfaction with the new system was evaluated. In total, 16 potential failure modes were recognized in the pre-implementation phase and 21 after Phocus Rx^® implementation. The total reduction of the criticality index was 67 percent, with a reduction of 46 percent in material preparation, 76 percent in drug production and 48 percent in quality control subprocesses. The relative risk reduction of compounding error rate was 63 percent after the implementation of Phocus Rx^®, from 0.045 to 0.017 percent. The high-priority recommendations defined were identification of the product with batch and expiration date from scanned bidimensional barcodes on drug vials and process improvements in image-based quality control. Overall satisfaction index was 8.30 (SD 1.06) for technicians and 8.56 (SD 1.42) for pharmacists (p = 0.655). The introduction of a new workflow management software system was an effective approach to increasing safety in the compounding procedures in the pharmacy department, according to the failure modes, effects and criticality analysis method.

Developing a cancer-specific trigger tool to identify treatment-related adverse events using administrative data

Background

As there are few validated tools to identify treatment‐related adverse events across cancer care settings, we sought to develop oncology‐specific “triggers” to flag potential adverse events among cancer patients using claims data.

Methods

322 887 adult patients undergoing an initial course of cancer‐directed therapy for breast, colorectal, lung, or prostate cancer from 2008 to 2014 were drawn from a large commercial claims database. We defined 16 oncology‐specific triggers using diagnosis and procedure codes. To distinguish treatment‐related complications from comorbidities, we required a logical and temporal relationship between a treatment and the associated trigger. We tabulated the prevalence of triggers by cancer type and metastatic status during 1‐year of follow‐up, and examined cancer trigger risk factors.

Results

Cancer‐specific trigger events affected 19% of patients over the initial treatment year. The trigger burden varied by disease and metastatic status, from 6% of patients with nonmetastatic prostate cancer to 41% and 50% of those with metastatic colorectal and lung cancers, respectively. The most prevalent triggers were abnormal serum bicarbonate, blood transfusion, non‐contrast chest CT scan following radiation therapy, and hypoxemia. Among patients with metastatic disease, 10% had one trigger event and 29% had two or more. Triggers were more common among older patients, women, non‐whites, patients with low family incomes, and those without a college education.

Conclusions

Oncology‐specific triggers offer a promising method for identifying potential patient safety events among patients across cancer care settings.

The Patient Perspective on Errors in Cancer Care: Results of a Cross-Sectional Survey

OBJECTIVE

The objective of this study was to explore medical oncology outpatients' perceived experiences of errors in their cancer care.

METHODS

A cross-sectional survey was conducted. English-speaking medical oncology outpatients aged 18 years or older were recruited from 9 Australian cancer treatment centers. Participants completed 2 paper-and-pencil questionnaires: an initial survey on demographic, disease and treatment characteristics upon recruitment; and a second survey on their experiences of errors in cancer care 1 month later.

RESULTS

A total of 1818 patients (80%) consented to participate, and of these, 1136 (62%) completed both surveys. One hundred forty-eight participants (13%) perceived that an error had been made in their care, of which one third (n = 46) reported that the error was associated with severe harm. Of those who perceived an error had been made, less than half reported that they had received an explanation for the error (n = 65, 45%) and only one third reported receiving an apology (n = 50, 35%) or being told that steps had been taken to prevent the error from reoccurring (n = 52, 36%). Patients with university or vocational level education (odds ratio [OR] = 1.6 [1.09-2.45], P = 0.0174) and those who received radiotherapy (OR = 1.72 [1.16-2.57]; P = 0.0076) or "other" treatments (OR = 3.23 [1.08-9.63]; P = 0.0356) were significantly more likely to report an error in care.

CONCLUSIONS

There is significant scope to improve communication with patients and appropriate responses by the healthcare system after a perceived error in cancer care.

A Radiation Oncology-Specific Automated Trigger Indicator Tool for High-Risk, Near-Miss Safety Events

PURPOSE

Error detection in radiation oncology relies heavily on voluntary reporting, and many adverse events and near misses likely go undetected. Trigger tools use existing data in patient charts to identify otherwise-unaccounted-for events and have been successfully employed in other areas of medicine. We developed an automated radiation oncology-specific trigger tool and validated it against near-miss data from a high-volume incident learning system (ILS).

METHODS AND MATERIALS

Twenty triggers were derived from an electronic radiation oncology information system. Data from the systems over an approximately 3.5-year period were split randomly into training and test sets. The probability of a high-grade (grade 3-4) near miss for each treatment course in the training set was estimated using a regularized logistic regression model. The predictive model was applied to the test set. Records for 25 flagged treatment courses with an ILS entry were reviewed to explore the association between triggers and near misses, and 25 flagged courses without an ILS entry were reviewed to detect unreported near misses.

RESULTS

Of the 3159 treatment courses analyzed, 357 had a grade 3 to 4 ILS entry; 2210 courses composed the training set, and the test set had 949 courses. Areas under the curve on the training and test sets were 0.650 and 0.652, respectively. Of 20 triggers, 9 reached statistical significance on univariate analysis. Fifty percent of the 25 treatment courses in the test set with the highest predicted likelihood of a high-grade near miss with an ILS entry had a direct relationship between the triggers and the near miss. Review of the 25 treatment courses with the highest predicted likelihood of high-grade near miss without an ILS entry found 2 unreported near-miss events.

CONCLUSIONS

The radiation oncology-specific automated trigger tool performed modestly and identified additional treatment courses with near-miss events. Radiation oncology trigger tools deserve further exploration.

Oral anticancer therapy project: Clinical utility of a specific home care nursing programme on behalf of Italian Association of Medical Oncology (AIOM)

AIMS AND OBJECTIVES

To assess the effectiveness of a specific home care nursing programme in addition to standard care in patients (pts) receiving oral anticancer treatments.

BACKGROUND

Oral anticancer therapy present challenges for pts since treatment is a home-based therapy. This study evaluates the potentiality of a home care nursing programme in decreasing hospital accesses for not severe toxicity.

METHODS

This is an open-label, multicentre, randomised trial including pts who were receiving an anticancer oral drug. The study complies with the CONSORT checklist published in 2010. Concomitant use of radiation therapy, intravenous or metronomic therapies, or the intake of previous oral drugs was not allowed. Pts were randomly assigned to home care nursing programme (A) or standard care (B). In arm A, dedicated nurses provided information to pts, a daily record on which pts would take note of drugs and dosages and a telephone monitoring during the first two cycles of therapy. The primary outcome was the reduction in improper hospital accesses for grade 1-2 toxicity according to CTCAE v4.0.

RESULTS

Out of 432 randomised pts, 378 were analysed (184 pts in arm A and 194 in arm B). Hospital accesses were observed in 41 pts in arm A and in 42 pts in arm B (22.3% vs. 21.6%, respectively). No difference was detected in proportion of improper accesses between arm A and arm B (29.3% vs. 23.8%, respectively).

CONCLUSIONS

Our experience failed to support the role of a specific home care nursing programme for pts taking oral chemotherapy. An improved attention to specific educational practice and information offered to pts can explain these results.

RELEVANCE TO CLINICAL PRACTICE

Our results underline the role of nurse educational practice and information offered to patients. A careful nurse information of patients about drugs is essential to reduce toxicities avoiding the opportunity of a specific home monitoring.

Medication errors in a cohort of pediatric patients with acute lymphoblastic leukemia on remission induction therapy in a tertiary care hospital in Mexico

INTRODUCTION

Medication errors (MEs) are the main type of preventable adverse events in medical care, as well as safety indicators in the medication processes. Advances in the quality of care in pediatric acute lymphoblastic leukemia (ALL) have enabled to improve clinical outcomes. However, ME epidemiology in pediatric oncology is still incipient in developing countries. In view of this, the objectives of this study were to estimate the incidence of MEs, determine their types and consequences, as well as their preventability in the induction treatment of children with ALL at Hospital Infantil de Mexico Federico Gómez.

METHODS

We reviewed the remission-induction chemotherapy records of children with ALL between January 2015 and December 2017. A two-phase review was carried out for ME identification and verification. The consequences of errors were determined by agreement between reviewers.

RESULTS

We reviewed 1762 chemotherapy orders involving 181 children. MEs were observed in 16.9% of orders and in 57.5% of patients. Prescription errors were the most common (93.3%), with wrong dose errors (90.2%) being predominant. Only 3.7% of wrong dose errors were intercepted, while 12.2% of the children experienced adverse drug events (ADEs) preceded by some wrong dose error.

CONCLUSIONS

MEs were common, since they occurred in 57.5% of children with ALL on induction treatment and involved 16.5% of chemotherapy orders. Only 3.7% of MEs were intercepted, while 12.2% of children had ADEs related to overdose. Measures are required to prevent calculation error in prescriptions, as well as training of the nursing staff to intercept MEs.

A cross-sectional study: medication safety among cancer in-patients in tertiary care hospitals in KPK, Pakistan

Background

Medication safety in cancer patients receiving complex medication regimens is an important problem in various settings. Medication related events, interceptions and interventions are not well described in this area. We intended to study incidence, types, settings and stages involved, root cause analysis, medication classes involved and the level of harm cause by medication errors in two hospitals providing oncology services comparatively. The severity of incidents and interventions are studied.

Methods

It was a prospective cross sectional study among cancer in-patients of two tertiary care hospitals of KPK. Scale by NCC-MERP was used for evaluation of all medication related incidents. The data obtained was analyzed by IBM SPSS statistics 22 with 95% confidence interval and used the same for other descriptive statistics.

Results

All medication orders were reviewed at both sites (Computerized Prescription Order Entry and HWP systems). Potential ADEs incidence was found high at site 2 (97.5%) while medication errors without harm was high at site 1 (97.5%). Most events occur at prescribing level 87.6 and 81.7% at both sites 1 and 2. Types highly reported involved improper dose 31.4 and 15.5%, monitoring error 14.6 and 15.2% at site 1 and 2. Medications involved in these incidents were antibiotics 44 and 12.7%, antiemetic 7.5 and 15.8% and antineoplastic 2.9 and 9.4% at site 1 and 2. Severity of 3.6 and 36.5% incidents had potential to cause harm at site 1 and 2. Root causes were human factors 62.6 and 72.3%, drug selection 33.6 and 38.8%, and dose selection 39.6 and 15.3% at sites 1 and 2. Contributing factors including staff training 33.6 and 24.3%, system for covering patient care 14.9 and 36.6%, communication system 2.4 and 20.3%, interruptions 9.7 and 7.3% and others 78.8 and 68.6% were highly reported. Preventability of medication errors was 99% at both sites. Intervention was taken in 90.5% events at site 1 (CPOE system) while the incidence lowest at site 2 (HWP system).

Conclusion

Medication related events are high among cancer in-patients at the site lacking updated electronic system for medication prescribing. Proper training about medication safety, reporting and interventions are required.

Chemotherapy medication errors

Although chemotherapy is a well established treatment modality, chemotherapy errors represent a potentially serious risk of patient harm. We reviewed published research from 1980 to 2017 to understand the extent and nature of medication errors in cancer chemotherapy, and to identify effective interventions to help prevent mistakes. Chemotherapy errors occur at a rate of about one to four per 1000 orders, affect at least 1-3% of adult and paediatric oncology patients, and occur at all stages of the medication use process. Oral chemotherapy use is a particular area of growing risk. Our knowledge of chemotherapy errors is drawn primarily from single-institution studies at university hospitals and referral centres, with a particular focus on prescription orders and pharmacy practices. Although the heterogeneity of research methods and measures used in these studies limits our understanding of this issue, the rate of chemotherapy error-related injuries is generally lower than those seen in comparable studies of general medical patients. Although many interventions show promise in reducing chemotherapy errors, most have little empirical support. Additional research is needed to understand and to mitigate the risk of chemotherapy medication errors.

Using Electronic Health Records to Identify Adverse Drug Events in Ambulatory Care: A Systematic Review

OBJECTIVE

We identified the methods used and determined the roles of electronic health records (EHRs) in detecting and assessing adverse drug events (ADEs) in the ambulatory setting.

METHODS

We performed a systematic literature review by searching PubMed and Google Scholar for studies on ADEs detected in the ambulatory setting involving any EHR use published before June 2017. We extracted study characteristics from included studies related to ADE detection methods for analysis.

RESULTS

We identified 30 studies that evaluated ADEs in an ambulatory setting with an EHR. In 27 studies, EHRs were used only as the data source for ADE identification. In two studies, the EHR was used as both a data source and to deliver decision support to providers during order entry. In one study, the EHR was a source of data and generated patient safety reports that researchers used in the process of identifying ADEs. Methods of identification included manual chart review by trained nurses, pharmacists, and/or physicians; prescription review; computer monitors; electronic triggers; International Classification of Diseases codes; natural language processing of clinical notes; and patient phone calls and surveys. Seven studies provided examples of search phrases, laboratory values, and rules used to identify ADEs.

CONCLUSION

The majority of studies examined used EHRs as sources of data for ADE detection. This retrospective approach is appropriate to measure incidence rates of ADEs but not adequate to detect preventable ADEs before patient harm occurs. New methods involving computer monitors and electronic triggers will enable researchers to catch preventable ADEs and take corrective action.

Root Cause Analysis of Oncology Adverse Events in the Veterans Health Administration

PURPOSE

Oncology providers are leaders in patient safety. Despite their efforts, oncology-related medical errors still occur, sometimes resulting in patient injury or death. The Veterans Health Administration (VHA) National Center of Patient Safety used data obtained from root cause analysis (RCA) to determine how and why these adverse events occurred in the VHA, and how to prevent future reoccurrence. This study details the types of oncology adverse events reported in VHA hospitals and their root causes and suggests actions for prevention and improvement.

METHODS

We searched the National Center for Patient Safety adverse event reporting database for RCA related to oncology care from October 1, 2013, to September 8, 2017, to identify event types, root causes, severity of outcomes, care processes, and suggested actions. Two independent reviewers coded these variables, and inter-rater agreement was calculated by κ statistic. Variables were evaluated using descriptive statistics.

RESULTS

We identified 48 RCA reports that specifically involved an oncology provider. Event types included care delays (39.5% [n = 19]), issues with chemotherapy (25% [n = 12]) and radiation (12.5% [n = 6]), other (12.5% [n = 6]), and suicide (10.5% [n = 5]). Of the 48 events, 27.1% (n = 13) resulted in death, 4.2% (n = 2) in severe harm, 18.8% (n = 9) in temporary harm, 20.8% (n = 10) in minimal harm, and 2.1% (n = 1) in no harm. The majority of root causes identified a need to improve care processes and policies, interdisciplinary communication, and care coordination.

CONCLUSION

This analysis highlights an opportunity to implement system-wide changes to prevent similar events from reoccurring. These actions include comprehensive cancer clinics, usability testing of medical equipment, and standardization of processes and policies. Additional studies are necessary to assess oncologic adverse events across specialties.

Chemotherapy administration standards and guidelines: The development of a resource document

There are no nationally recognised guidelines for the handling and administration of chemotherapy in South Africa. The Independent Clinical Oncology Network’s Chemotherapy Administration Standards and Guidelines Resource Documentwas developed over 2 years and first introduced at a South African international oncology conference in 2017. A working group consisting of oncologists and oncology nurses was set up to address this deficiency. Pragmatic guidelines suitable to a wide range of local chemotherapy administration practices were developed using an iterative, multidisciplinary, collaborative process. The consensus was that these guidelines should be appropriate to the South African context. Safety, standard operational procedures, recommended professional competencies and training were central to the document. Guidelines for prescribing, storing, mixing, dispensing, administering and disposing of chemotherapy were included. Patient consent and involvement, patient and staff safety, recommended professional competencies, management of accidents and errors, error reporting and local legal requirements are dealt with in detail. The hope is that these guidelines will be used as a resource document for South African chemotherapy practices, both public and private. The document is supported by standard operating procedures and action steps. These were developed to promote the use of the guidelines and to support pragmatic quality assurance measures at practice level. These standards and guidelines will be regularly updated, based on needs identified and deficiencies noted.

Leveraging supply chain infrastructure to advance patient safety in community health-care settings

Purpose The purpose of this paper is to examine the opportunity for supply chain processes and infrastructure to reduce the risk of medical error and create traceability of adverse events in community care settings. Patient safety has become an important area of focus over the past few decades, with medical error now accounting for the third most common cause of death in Canada and the USA. The majority of patient safety studies to date have focused specifically on safety in hospital settings; however, deaths and harm experienced by patients in the community (home care, long-term care, complex care and rehabilitation settings) are not well understood. Design/methodology/approach This paper discusses the evidence that adverse events occur at similar, if not more, frequent rates in community care settings. Findings The authors propose that above and beyond current efforts to increase awareness and promote a "safety culture" in health-care settings, system infrastructure should be designed in a way that enables clinicians to provide the safest care possible. There is currently no line of sight across the health-care continuum. The authors suggest that improving system infrastructure would reduce the occurrence of adverse events. Originality/value Such visibility across the continuum of care holds the potential to transform health-care in Canada from a fragmented system, where information is inadequately captured and transferred from provider to provider, to a system that provides complete, accurate and up-to-date information regarding patient care, procedures, medications and outcomes so as to provide the best and safest care possible. System visibility achieves quality and safe care, which is transparent and accountable and achieves value for patients.

Cancer risk assessment in modern radiotherapy workflow with medical big data

Modern radiotherapy (RT) is being enriched by big digital data and intensive technology. Multimodality image registration, intelligence-guided planning, real-time tracking, image-guided RT (IGRT), and automatic follow-up surveys are the products of the digital era. Enormous digital data are created in the process of treatment, including benefits and risks. Generally, decision making in RT tries to balance these two aspects, which is based on the archival and retrieving of data from various platforms. However, modern risk-based analysis shows that many errors that occur in radiation oncology are due to failures in workflow. These errors can lead to imbalance between benefits and risks. In addition, the exact mechanism and dose-response relationship for radiation-induced malignancy are not well understood. The cancer risk in modern RT workflow continues to be a problem. Therefore, in this review, we develop risk assessments based on our current knowledge of IGRT and provide strategies for cancer risk reduction. Artificial intelligence (AI) such as machine learning is also discussed because big data are transforming RT via AI.

Improving the Safety and Quality of Systemic Treatment Regimens in Computerized Prescriber Order Entry Systems

PURPOSE

Systemic treatment (ST) computerized prescriber order entry (CPOE) and preprinted orders (PPO) are proven to reduce errors. There is no known guidance in oncology to facilitate high-quality, accurate regimen development and review; hence, this was identified as a system-wide gap. This provincial initiative aimed to improve the quality of oncology regimens through a comprehensive review of systemic treatment (ST) regimens and the development of standards.

METHODS

A system-wide analysis of all active regimens (both CPOE and PPO) to ensure they were built as intended was conducted in 2015. Thirty-five hospitals (on behalf of 75 treatment facilities) were asked to report any unintentional discrepancies and details of the maintenance review process. Discrepancies were compiled, categorized, and analyzed for potential to cause harm. In addition, a multidisciplinary expert working group was formed to create best practice recommendations.

RESULTS

The review yielded a 94% response rate and took a total of 18 months to complete (70% completed within 9 months). The average number of regimens reviewed was 336 (range, 15 to 700; n = 9). Unintentional discrepancies were reported by nine hospitals (27%). A total of 369 discrepancies were reported (average, 55 per hospital), and 28 were deemed to have a moderate potential for harm. Only two hospitals (6%) had an established maintenance process; now, all have standard processes for review. Consensus-based recommendations for ST-CPOE and PPO regimen development and maintenance were developed.

CONCLUSION

The review identified unintentional discrepancies and, because of the potential for patient harm, corrective action has been taken. Identified discrepancies have been amended, and standard regimen development and maintenance review processes are now implemented system-wide to improve the quality and safety of systemic treatment delivery.