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Canadian OnCOlOgy nursing JOurnal • VOlume 26, issue 3, summer 2016 reVue Canadienne de sOins infirmiers en OnCOlOgie
FEA TUR ES /R U bR iq UE S
leADersHiP cOluMN
Medication errors and shift to a culture of patient safety and high reliability
by Janice Chobanuk
M
edication errors with antineoplastic drugs can be disastrous to patients due to the drugs’ high toxicity and lim- ited therapeutic index. Cancer patients often require numerous complex and often toxic therapies for treatment, which requires careful coordination of care. In a study involving 6,607 antineoplastic pre- scriptions, the researchers found an error rate of 5.2% (449). The highest errors were prescription errors (91%), followed with pharmaceutical (8%) and adminis- tration errors (1%). The researchers esti- mated that 13.4% of these errors would have resulted in a patient injury, 2.6%in permanent damage, and 2.6% would have affected the prognosis of the cancer patient. Gandhi et al. (2005) found the chemotherapy error rate was 3% in 3,200 chemotherapy orders for adult and pediat- ric patients. In a study involving pediatric and adult oncology patients, the authors found chemotherapy errors were 0.3 to 5.8 per 100 visits (Walsh et al., 2009).
Many oncology-nursing leaders are recognizing the importance of treating chemotherapy as a high-risk activity.
Nursing leaders are actively promot- ing transition to a patient safety and high-reliability culture in order to enhance patient safety in oncology set- tings (Ranchon et al., 2012). This para- digm shift requires strong leadership support, the use of principles of high reliability and a patient-centric focus, as well as continuous quality improve- ment initiatives. The strategy involves leaders addressing issues such as inher- ent weaknesses in processes in the can- cer setting, clinical designs of buildings, the impact of computer programs, staff- ing levels, equipment issues, and other factors that influence the local working conditions. A focus on safety requires oncology leaders to move away from reactive responses to error reports, and reviewing individual actions and the error, to embrace a proactive sys- tem-wide preventative approach.
Globally, leaders in health care facilities are starting to incorporate the exper- tise and lessons learned from high- risk groups with low failure rates, such as aviation and nuclear power plants, into their safety strategic approach (Ranchon et al., 2012). These organiza- tions have developed an array of tools for assessing organizational factors that have the potential to lead to a failure or error. The tools address issues such as supervision, planning, communication, training, and maintenance. Instead of a retrospective analysis of adverse events, these tools enable oncology leaders to transition to a more proactive culture of
patient safety and monitor safety trends in the organization on a continual basis.
Chemotherapy management is a hazardous and challenging procedure that oncology leaders need to recog- nize as a high-risk activity. Mistakes can occur any time and at any stage in the process—from the prescription, prepa- ration, and dispensing to the adminis- tration. The increasing number of oral chemotherapy agents adds a new chal- lenge for oncology facilities. Shah et al.
(2016) reported that 22 interventions (35%) were required to prevent poten- tial errors in 63 oral medication orders over a seven-month period. Most of the errors were related to dosage adjust- ment, the identification of interacting drugs, and additional drug monitoring.
Oncology nursing leaders are well positioned to drive a culture shift to patient safety and high reliability. This change involves tactical strategies such as education, safety committees, safety protocols and procedures, use of tech- nology, a no blame atmosphere, and a focus on zero medication errors (Ranchon, McEachan, Giles, Sirriyeh, Watt, & Wright, 2012). Other examples of initiatives include independent double checks, bar codes, electronic order-en- try systems with decision support, and smart pump technology. Oncology nurs- ing leaders need to be actively engaged in patient safety improvement to impact on patients, employees, physicians, and other clinicians in the organization.
reFereNces
Gandhi, T.K., Bartel, S.B., Shulman, L.N., Verrier, D., Burdick, E., Cleary, A., … Bates, D.W. (2005). Medication safety in the ambulatory chemotherapy setting. Cancer, 104, 2477–2483. doi:10.1002/cncr.21442 Ranchon, F., Salles, G., Späth, H.,
Schwiertz, V., Vantard, N., Parat, S., … Rioufol, C. (2011). Chemotherapeutic errors in hospitalised cancer patients:
Attributable damage and extra costs. BMC Cancer, 111(478), 2–10.
doi:10.1186/1471-2407-11-478
Ranchon, L., McEachan, R.C., Giles, S.J., Sirriyeh, R., Watt, I.S., & Wright, J.
(2012). Development of an evidence- based framework of factors contributing to patient safety incidents in hospital settings: A systematic review. BMJ Quality and Safety, 21(5), 369–380.
doi:10.1136/bmjqs-2011-000443
Shah, N.N., Casella, E., Capozzi, D., McGettigan, S., Gangadhar, T.C., Schuchter, L., & Myers, J.S. (2016).
Improving the safety of oral
chemotherapy at an academic medical center. Journal of Oncology Practice, 12(1), 71–76. doi:10.1200/JOP.2015.007260 Walsh, K.E., Dodd, K.S., Seetharaman, K.,
Roblin, D.W., Herrinton, L.J., Worley, A.V., … Gurwitz, J.H. (2009).
Medication errors among adults and children with cancer in the outpatient setting. Journal of Clinical Oncology, 27(6), 891–896. doi:10.1200/
JCO.2008.18.6072
AbOut tHe AutHOr
Janice Chobanuk, BScN, MN, CHPCN(C), CON(C), Director Ambulatory Care and Systemic Therapy, Community Oncology, Alberta Health Services, CancerControl Alberta Edmonton, Alberta
