2.50
Hdl Handle:
http://hdl.handle.net/10755/164127
Category:
Abstract
Type:
Presentation
Title:
The ACE Project: Avoiding Chemotherapy Errors in a Blended Medical/Surgical/Oncology Unit
Author(s):
Garzo Saria, Marlon; Rome, Sandra Irene
Author Details:
Marlon Garzo Saria, MSN, RN, CNS(s), OCN, UCSD Medical Center, San Diego, California, USA, email: nacnsorg@nacns.org; Sandra Irene Rome, MN, RN, AOCN, Cedars Sinai Medical Center, San Diego, California, USA
Abstract:
Problem: Failure to identify chemotherapy infusion errors may lead to catastrophic consequences that may involve loss of life or limb. Significance: The high occurrence of preventable errors in hospitals continues to be a concern. Chemotherapy-certified nurses provide the last link in the process steps in the administration of chemotherapy and are therefore in the best position to identify and reduce errors and improve quality outcomes for patients. Purpose: To provide chemotherapy-certified nurses with a tool to identify and eliminate errors in chemotherapy administration. Background: The public health problem of death and serious harm resulting from medication errors has gained national attention largely through an error that caused the death of Boston Globe medical writer Betsy Lehman of a chemotherapy overdose. Most recently, the Joint Commission on Accreditation of Health Organizations (JCAHO) has issued a requirement for hospitals to perform one Failure Mode Effects Analysis (FMEA) each year in light of the excessive occurrence of preventable errors. FMEA recognizes that humans will err; however, these errors need to be acknowledged not as a result of individual incompetence but rather of multiple breakdowns throughout the healthcare system. Errors related to chemotherapy administration result from a multitude of factors within the healthcare system. Generally, errors may occur at any time during the entire chemotherapy administration process including staff education and competence; ordering, transcribing, dosing, verification, and preparation/dispensing; administration; and the influence of the work environment. Contrary to what most chemotherapy-certified nurses would assume, Reed, et al. (1998) revealed that medication error rates were not correlated with patient acuity but were more likely to indicate quality of nursing care. Chemotherapy-certified nurses play an important role in the chemotherapy administration process and for that reason must assume an active role in the identification and reduction of errors to improve quality outcomes for patients. Practice Innovation: A descriptive design will be used to examine and describe the practices of chemotherapy administration prior to and after the introduction of a Chemotherapy Verification Form. Chemotherapy-certified nurses will be asked to participate in a study requesting them to carry out mock-up chemotherapy orders utilizing current policies and procedures. The same nurses will then be provided with a Chemotherapy Verification Form and will again be asked to carry out the same orders. To emphasize the simplicity and fool-proof design of the form, no verbal instructions or directions will be given on how to utilize the form. Expected Outcome: Based on anecdotal reports of non-verification of chemotherapy orders and non-adherence to the current policies and procedures, errors may occur during the chemotherapy administration process. Utilizing the Chemotherapy Verification Form, nurses will be prompted to verify data that may inadvertently be missed. Conclusion: Oncology nurses have acquired the knowledge and skills necessary to administer treatments and provide services safely. Their aptitude to identify errors prior to the administration of chemotherapy will greatly reduce the risk of serious and sometimes fatal consequences. Implications for Practice: Chemotherapy administration involves the effort of a team of health professionals, including the oncologist, pharmacist, nurse, ancillary staff, and the patient. Albeit everyone is responsible for providing safe and quality care, it is ultimately the chemotherapy-certified nurse who will provide the last safeguard against an error that may have occurred in the process. Providing nurses with a tool that is convenient and functional leaves nothing to chance, underscoring their role in delivering safe quality care.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
2005
Conference Name:
CNS Leadership: Navigating the Healthcare Environment Toward Excellence
Conference Host:
NACNS - National Association of Clinical Nurse Specialists
Conference Location:
Orlando, Florida, USA
Description:
Conference theme: CNS Leadership: Navigating the Healthcare Environment Toward Excellence, held on March 9�12, 2005 in Orlando, Florida, USA
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.type.categoryAbstracten_US
dc.typePresentationen_GB
dc.titleThe ACE Project: Avoiding Chemotherapy Errors in a Blended Medical/Surgical/Oncology Uniten_GB
dc.contributor.authorGarzo Saria, Marlonen_US
dc.contributor.authorRome, Sandra Ireneen_US
dc.author.detailsMarlon Garzo Saria, MSN, RN, CNS(s), OCN, UCSD Medical Center, San Diego, California, USA, email: nacnsorg@nacns.org; Sandra Irene Rome, MN, RN, AOCN, Cedars Sinai Medical Center, San Diego, California, USAen_US
dc.identifier.urihttp://hdl.handle.net/10755/164127-
dc.description.abstractProblem: Failure to identify chemotherapy infusion errors may lead to catastrophic consequences that may involve loss of life or limb. Significance: The high occurrence of preventable errors in hospitals continues to be a concern. Chemotherapy-certified nurses provide the last link in the process steps in the administration of chemotherapy and are therefore in the best position to identify and reduce errors and improve quality outcomes for patients. Purpose: To provide chemotherapy-certified nurses with a tool to identify and eliminate errors in chemotherapy administration. Background: The public health problem of death and serious harm resulting from medication errors has gained national attention largely through an error that caused the death of Boston Globe medical writer Betsy Lehman of a chemotherapy overdose. Most recently, the Joint Commission on Accreditation of Health Organizations (JCAHO) has issued a requirement for hospitals to perform one Failure Mode Effects Analysis (FMEA) each year in light of the excessive occurrence of preventable errors. FMEA recognizes that humans will err; however, these errors need to be acknowledged not as a result of individual incompetence but rather of multiple breakdowns throughout the healthcare system. Errors related to chemotherapy administration result from a multitude of factors within the healthcare system. Generally, errors may occur at any time during the entire chemotherapy administration process including staff education and competence; ordering, transcribing, dosing, verification, and preparation/dispensing; administration; and the influence of the work environment. Contrary to what most chemotherapy-certified nurses would assume, Reed, et al. (1998) revealed that medication error rates were not correlated with patient acuity but were more likely to indicate quality of nursing care. Chemotherapy-certified nurses play an important role in the chemotherapy administration process and for that reason must assume an active role in the identification and reduction of errors to improve quality outcomes for patients. Practice Innovation: A descriptive design will be used to examine and describe the practices of chemotherapy administration prior to and after the introduction of a Chemotherapy Verification Form. Chemotherapy-certified nurses will be asked to participate in a study requesting them to carry out mock-up chemotherapy orders utilizing current policies and procedures. The same nurses will then be provided with a Chemotherapy Verification Form and will again be asked to carry out the same orders. To emphasize the simplicity and fool-proof design of the form, no verbal instructions or directions will be given on how to utilize the form. Expected Outcome: Based on anecdotal reports of non-verification of chemotherapy orders and non-adherence to the current policies and procedures, errors may occur during the chemotherapy administration process. Utilizing the Chemotherapy Verification Form, nurses will be prompted to verify data that may inadvertently be missed. Conclusion: Oncology nurses have acquired the knowledge and skills necessary to administer treatments and provide services safely. Their aptitude to identify errors prior to the administration of chemotherapy will greatly reduce the risk of serious and sometimes fatal consequences. Implications for Practice: Chemotherapy administration involves the effort of a team of health professionals, including the oncologist, pharmacist, nurse, ancillary staff, and the patient. Albeit everyone is responsible for providing safe and quality care, it is ultimately the chemotherapy-certified nurse who will provide the last safeguard against an error that may have occurred in the process. Providing nurses with a tool that is convenient and functional leaves nothing to chance, underscoring their role in delivering safe quality care.en_GB
dc.date.available2011-10-27T11:42:32Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T11:42:32Z-
dc.conference.date2005en_US
dc.conference.nameCNS Leadership: Navigating the Healthcare Environment Toward Excellenceen_US
dc.conference.hostNACNS - National Association of Clinical Nurse Specialistsen_US
dc.conference.locationOrlando, Florida, USAen_US
dc.descriptionConference theme: CNS Leadership: Navigating the Healthcare Environment Toward Excellence, held on March 9�12, 2005 in Orlando, Florida, USAen_US
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.en_US
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