Significant and Sustained Reduction in Chemotherapy Errors Through Improvement Science

Significant and Sustained Reduction in Chemotherapy Errors Through Improvement Science
Interest in reducing medical errors in hospitals has been steadily gaining momentum over the last 1-2 decades. As it relates to chemotherapy, with a narrow therapeutic index and high potential for harm, a number of large US hospitals have published on the systematic changes they have made within their departments in this regard.
This is a QI publication is from the Cincinnati children’s hospital, an academic institution that sees > 400 new cancer diagnoses per year and has a baseline error rate of 3.9 per 1000 chemotherapy doses and uses a completely integrated electronic health record (EPIC/BEACON). Of note, 64% of near miss errors were in prescribing and hence directly relevant to physicians.
With the launch of a chemotherapy safety working group, implementation of an additional error reporting system (to capture both near misses and errors that reached the patient) along with a daily chemotherapy safety huddle and creation of noise-reduced chemo ordering ‘safety zones’, they reduced their error rate by 50% (1.9/1000). This reduction in errors was sustained over time.
This study was limited by its generalizability to centers that are smaller in size and do not utilize an integrated electronic health record and/or may be resource limited in other ways. There was also limited discussion on educational initiatives that were implemented for prescribers (MDs) and chemo administrators (nurses) as a result of this project.
Implementing additional error surveillance systems and creating a non-punitive and transparent culture of error reporting is an effective strategy to reduce chemotherapy related errors in a large academic hospital. From an MD perspective, more work needs to be published on prescriber specific interventions that can guide educational initiatives with broad generalizability.

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