2.50
Hdl Handle:
http://hdl.handle.net/10755/165731
Category:
Abstract
Type:
Presentation
Title:
To Err is Human-Designing Safer Systems for Chemotherapy Administration
Author(s):
Taibbi, Rose
Author Details:
Rose Taibbi, North Shore University Hospital, Manhasset, New York, USA
Abstract:
Chemotherapy errors can be lethal. Investigations of highly publicized chemotherapy errors show that multiple system failures must occur for an error to reach the patient. All disciplines involved in ordering, preparing/dispensing, and administration of chemotherapy must be highly trained and receive ongoing education. Antineoplastic agents are unique in that there is such a wide array of doses and schedules used. To address the concerns within our institution and identify areas for improvement, a multidisciplinary Chemotherapy Performance Improvement Committee meets monthly. The literature clearly recommends the use of computerized ordering systems. However, for institutions without computerized programs, other interventions must be developed, implemented, and re-evaluated on an ongoing basis. Review of errors with root cause analysis is crucial to understanding your institution's process and potential for improvement. In addition, much can be learned from "potential errors." Our focus is on review of orders that require intervention or revision before the patient is treated. We identified five levels of severity with the first four reflecting problems that were corrected prior to treatment. The fifth level reflects any error that reached the patient. Education focuses on heightening awareness of the need to report all orders that required interventions. We stressed non-punitive action, the ability to learn from "potential errors," and identification of methods to prevent actual errors. Chemotherapy order writing guidelines, maximum dosing charts, and guidelines for administration and monitoring were developed. Most importantly, a multidisciplinary algorithm of check processes was developed to ensure comprehensive review of each order by physicians, pharmacists, and nurses. Each discipline understands their accountability in the process. "Potential errors" are tracked for trends, and staff is educated accordingly. Staff is recognized for their assistance with problem identification and reporting. Over the past year, we administered 50,107 drug preparations, identified 484 "potential errors," and had one actual error. Despite the increasing complexity of treatments, our error rate was .002% using the protocols discussed. Designing safer systems protects patients and allows oncology nurses to implement all possible safeguards as we strive for an error rate of zero.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
2002
Conference Name:
27th Annual Oncology Nursing Society Congress
Conference Host:
Oncology Nursing Society
Conference Location:
Washington, D.C., 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.titleTo Err is Human-Designing Safer Systems for Chemotherapy Administrationen_GB
dc.contributor.authorTaibbi, Roseen_US
dc.author.detailsRose Taibbi, North Shore University Hospital, Manhasset, New York, USAen_US
dc.identifier.urihttp://hdl.handle.net/10755/165731-
dc.description.abstractChemotherapy errors can be lethal. Investigations of highly publicized chemotherapy errors show that multiple system failures must occur for an error to reach the patient. All disciplines involved in ordering, preparing/dispensing, and administration of chemotherapy must be highly trained and receive ongoing education. Antineoplastic agents are unique in that there is such a wide array of doses and schedules used. To address the concerns within our institution and identify areas for improvement, a multidisciplinary Chemotherapy Performance Improvement Committee meets monthly. The literature clearly recommends the use of computerized ordering systems. However, for institutions without computerized programs, other interventions must be developed, implemented, and re-evaluated on an ongoing basis. Review of errors with root cause analysis is crucial to understanding your institution's process and potential for improvement. In addition, much can be learned from "potential errors." Our focus is on review of orders that require intervention or revision before the patient is treated. We identified five levels of severity with the first four reflecting problems that were corrected prior to treatment. The fifth level reflects any error that reached the patient. Education focuses on heightening awareness of the need to report all orders that required interventions. We stressed non-punitive action, the ability to learn from "potential errors," and identification of methods to prevent actual errors. Chemotherapy order writing guidelines, maximum dosing charts, and guidelines for administration and monitoring were developed. Most importantly, a multidisciplinary algorithm of check processes was developed to ensure comprehensive review of each order by physicians, pharmacists, and nurses. Each discipline understands their accountability in the process. "Potential errors" are tracked for trends, and staff is educated accordingly. Staff is recognized for their assistance with problem identification and reporting. Over the past year, we administered 50,107 drug preparations, identified 484 "potential errors," and had one actual error. Despite the increasing complexity of treatments, our error rate was .002% using the protocols discussed. Designing safer systems protects patients and allows oncology nurses to implement all possible safeguards as we strive for an error rate of zero.en_GB
dc.date.available2011-10-27T12:23:53Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T12:23:53Z-
dc.conference.date2002en_US
dc.conference.name27th Annual Oncology Nursing Society Congressen_US
dc.conference.hostOncology Nursing Societyen_US
dc.conference.locationWashington, D.C., 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.-
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