Maureen Connor

Multidisciplinary approaches to reducing error and risk in a patient care setting

In 1995, a medication error at Bostons Dana-Farber Cancer Institute (DFCI) that received intense media scrutiny, transformed the Institute in many ways. Primarily, patient safety became a major priority that led to Institute-wide organizational learning. As a result, DFCI emerged as a national leader in the patient safety movement. A key factor believed to have contributed to this effort was the use of a multidisciplinary team approach to identifying and preventing errors, with the patient and family members as an integral part of the team. In addition to teamwork, other activities included implementing a new chemotherapy order entry system, transforming the culture to a non-punitive one where staff are encouraged to openly discuss errors and safety issues, and introducing a root cause analysis process for error/near miss investigations. Several guiding principles served as the foundation for the efforts including: 1) systems, not individuals, must be the focus of safety initiatives; 2) organizations must create a non-punitive culture; 3) changes must be hard-wired into systems; and 4) multidisciplinary participation, including patients and families, is critical to success.

Medication errors involving oral chemotherapy

Given the expanding use of oral chemotherapies, the authors set out to examine errors in the prescribing, dispensing, administration, and monitoring of these drugs.

Simplified surveillance for nosocomial bloodstream infections

OBJECTIVE To compare a surveillance definition of noso comial bloodstream infections requiring only microbiology data to the Centers for Disease Control and Preventions (CDC) current definition. SETTING Six teaching hospitals. METHODS We classified a representative sample of 73 positive blood cultures from six hospitals growing common skin contaminant isolates using a definition for bacteremia requiring only microbiology data and the CDC definition for primary bloodstream infection (National Nosocomial Infections Surveillance [NNIS] System review method). The classifications assigned during routine prospective surveillance also were noted, and the time required to classify isolates by the two methods was compared. RESULTS Among 65 blood cultures growing common skin contaminant isolates obtained from adults, the agreement rate between the microbiology data method and the NNIS review method was 91%. Agreement was significantly poorer for the eight blood cultures growing common skin contaminant isolates obtained from pediatric patients. The microbiology data method requires approximately 20 minutes less time per isolate than does routine surveillance. CONCLUSIONS A definition based on microbiology data alone yields the same result as the CDCs definition in the large majority of instances. It is more resource-efficient than the CDCs current definition.

Medication Safety of Five Oral Chemotherapies: A Proactive Risk Assessment

PURPOSE Oral chemotherapies represent an emerging risk area in ambulatory oncology practice. To examine the hazards associated with five oral chemotherapies, we performed a proactive risk assessment. METHODS WE CONVENED INTERDISCIPLINARY TEAMS AND CONDUCTED FAILURE MODE AND EFFECTS ANALYSES (FMEAS) FOR FIVE ORAL CHEMOTHERAPY AGENTS: capecitabine, imatinib, temozolomide, 6-mercaptopurine, and an investigational agent. This involved the creation of process maps for each medication, identification of failure modes, selection of high-risk failure modes, and development of recommendations to mitigate these risks. We analyzed the number of steps and types of failure modes and compared this information across the study drugs. RESULTS Key vulnerabilities include patient education about drug handling and adverse effects, prescription writing, patient self-administration and medication adherence, and failure to monitor and manage toxicities. Many of these failure modes were common across the five oral chemotherapies, suggesting the presence of common targets for improvement. Streamlining the FMEA itself may promote the dissemination of this method. CONCLUSION Each stage of the medication process poses risks to the safe use of oral chemotherapies. FMEAs may identify opportunities to improve medication safety and reduce the risk of patient harm.

Perceptions and Experiences of Patients Receiving Oral Chemotherapy

Although many patients prefer orally administered cancer therapy (including oral chemotherapy) because of its convenience, the shift from hospital to home-based administration creates concerns. This article explores the perceptions and experiences of oral chemotherapy users and their caregivers to assess vulnerabilities and improvement opportunities at each stage of the medication process: choosing oral chemotherapy, prescribing, dispensing, administering, and monitoring. The authors recruited 15 current and former oral chemotherapy users, as well as caregivers who administered the medications to children, to participate in one of two focus group sessions at a comprehensive cancer center. Participants largely were satisfied with oral cancer therapy but raised concerns regarding their lack of preparedness for side effects and their unfamiliarity with the possible techniques to mitigate drug toxicity. Participants also described difficulties obtaining medications through retail pharmacies. Parents of pediatric patients with cancer indicated concerns regarding their childrens emotional health and correct medication administration. Participants believed that the initial prescribing encounter should have included more education, and they also wanted more frequent follow-up by healthcare practitioners. As oral cancer therapy is used more widely, oncology healthcare providers will need to create robust mechanisms to support their safe use.

Enhancing safety reporting in adult ambulatory oncology with a clinician champion: a practice innovation.

This article examines whether a patient safety “champion” on an ambulatory chemotherapy infusion unit can increase reporting of adverse events and close calls. Reporting rates increased substantially on both intervention and control units. It was accompanied by more reports of medical errors and conditions that worried staff and fewer reports of service quality incidents. The facilitated reporting method described here is a novel approach to incident reporting, complements the spontaneous reporting systems used in hospitals and some ambulatory care settings, and may help to build a safety culture. By identifying errors and worrisome conditions, it may help managers identify problems before they lead to harm.