DECREASING THE RISK OF CHEMOTHERAPY ERRORS THROUGH A FAILURE MODES AND EFFECTS ANALYSIS (FMEA) AND A FOCUS PDCA (PLAN, DO, CHECK, ACT) QUALITY IMPROVEMENT MODEL

2.50
Hdl Handle:
http://hdl.handle.net/10755/165108
Category:
Abstract
Type:
Presentation
Title:
DECREASING THE RISK OF CHEMOTHERAPY ERRORS THROUGH A FAILURE MODES AND EFFECTS ANALYSIS (FMEA) AND A FOCUS PDCA (PLAN, DO, CHECK, ACT) QUALITY IMPROVEMENT MODEL
Author(s):
Roesser, Karen
Author Details:
Karen Roesser, RN MS AOCN, Oncology Clinical Nurse Specialist, The Thomas Johns Cancer Center, Richmond, Virginia, USA, email: karen.roesser@hcahealthcare.com
Abstract:
Schulmeister reported that sixty-three percent of nurses related that chemotherapy errors have occurred in their practice. The end result may be increased patient morbidity, mortality, and/or lawsuits related to the nurseÆs role in chemotherapy administration. Therefore, every effort to ensure and improve safety mechanisms related to chemotherapy needs to be undertaken to prevent chemotherapy errors from ever occurring. The purpose of this project was to systematically evaluate the processes associated with chemotherapy administration at our institution and where potential problem areas were. This included a review of the process in our infusion center, medical, and surgical oncology units. A team was developed which consisted of staff nurses, pharmacists, nursing management, the oncology clinical nurse specialist, and the patient safety officer. The team utilized the FMEA methodology and identified potential problem areas and their root causes. Each problem area was rated and given a risk priority score according to how likely it was to occur and the consequences of it. These FMEA results were incorporated into patient safety performance improvement activities using the FOCUS PDCA methodology. As a result of this, a new chemotherapy order form was developed with input from this team, our physicians, and our cancer committee. The team identified the following areas to be of highest risk related to the chemotherapy process which was in place: chemotherapy ordering form incomplete, order clarification not communicated, and AUC dosing formula not known. The evaluation of our newly revised chemotherapy ordering form has been error free to date. The use of a FMEA related to the chemotherapy process is particularly beneficial in evaluating processes for possible failures and to prevent them by correcting the processes proactively rather than reacting to adverse events after failures have occurred. Used in combination with other tools such as the PDCA, a new chemotherapy order form was developed which will continue to be evaluated through.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
2007
Conference Name:
32nd Annual Oncology Nursing Society Congress
Conference Host:
Oncology Nursing Society
Conference Location:
Las Vegas, Nevada, 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.titleDECREASING THE RISK OF CHEMOTHERAPY ERRORS THROUGH A FAILURE MODES AND EFFECTS ANALYSIS (FMEA) AND A FOCUS PDCA (PLAN, DO, CHECK, ACT) QUALITY IMPROVEMENT MODELen_GB
dc.contributor.authorRoesser, Karenen_US
dc.author.detailsKaren Roesser, RN MS AOCN, Oncology Clinical Nurse Specialist, The Thomas Johns Cancer Center, Richmond, Virginia, USA, email: karen.roesser@hcahealthcare.comen_US
dc.identifier.urihttp://hdl.handle.net/10755/165108-
dc.description.abstractSchulmeister reported that sixty-three percent of nurses related that chemotherapy errors have occurred in their practice. The end result may be increased patient morbidity, mortality, and/or lawsuits related to the nurseÆs role in chemotherapy administration. Therefore, every effort to ensure and improve safety mechanisms related to chemotherapy needs to be undertaken to prevent chemotherapy errors from ever occurring. The purpose of this project was to systematically evaluate the processes associated with chemotherapy administration at our institution and where potential problem areas were. This included a review of the process in our infusion center, medical, and surgical oncology units. A team was developed which consisted of staff nurses, pharmacists, nursing management, the oncology clinical nurse specialist, and the patient safety officer. The team utilized the FMEA methodology and identified potential problem areas and their root causes. Each problem area was rated and given a risk priority score according to how likely it was to occur and the consequences of it. These FMEA results were incorporated into patient safety performance improvement activities using the FOCUS PDCA methodology. As a result of this, a new chemotherapy order form was developed with input from this team, our physicians, and our cancer committee. The team identified the following areas to be of highest risk related to the chemotherapy process which was in place: chemotherapy ordering form incomplete, order clarification not communicated, and AUC dosing formula not known. The evaluation of our newly revised chemotherapy ordering form has been error free to date. The use of a FMEA related to the chemotherapy process is particularly beneficial in evaluating processes for possible failures and to prevent them by correcting the processes proactively rather than reacting to adverse events after failures have occurred. Used in combination with other tools such as the PDCA, a new chemotherapy order form was developed which will continue to be evaluated through.en_GB
dc.date.available2011-10-27T12:12:40Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T12:12:40Z-
dc.conference.date2007en_US
dc.conference.name32nd Annual Oncology Nursing Society Congressen_US
dc.conference.hostOncology Nursing Societyen_US
dc.conference.locationLas Vegas, Nevada, 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.-
All Items in this repository are protected by copyright, with all rights reserved, unless otherwise indicated.