Mitigating risk of preventable medical errors across a network through event sharing.

234 Background: Medical errors are the 4th leading cause of death in the US. Oncology providers are not immune to preventable medical errors occurring in the treatment of their patients. As a national network of five hospitals that specialize in the treatment of patients fighting complex or advanced-stage cancer, clinicians and quality professionals recognized an opportunity to encourage and formalize the process of sharing safety events, lessons learned, and action plans to mitigate the risk of repeat occurrence. Methods: An Alert Notification process was established consisting of an algorithm depicting two avenues for action when an event occurs. If the event is considered urgent, characterized by immediate high-risk of repeat occurrence or high-risk of severe harm, an alert is called. The hospital nursing officers and quality directors along with the corporate director of pharmacy and vice president of quality/safety convene within 24 hours of the event to: 1) resolve or “halt” the process; 2) escalate if needed; and 3) formulate a communication plan regarding any change in process. If the event does not meet urgent criteria, the hospital conducts a root cause analysis (RCA) or common cause analysis, depending upon the algorithm. A summary of RCAs conducted for events resulting in temporary or permanent severe harm or worse are presented at the network’s monthly safety meeting, with action plans implemented across sites. Results: The notification algorithm was implemented in September 2017. Since its inception, three events have been communicated using the Urgent Alert Notification, including a syringe recall that halted use at all sites until all lot numbers could be checked, and affected syringes pulled. Several events and near misses have been communicated using the non-urgent process, including for example, discussion of a retained foreign object which resulted in review of processes for orienting staff to new products. Conclusions: The process has promoted communication across the five centers as an error prevention strategy. The sharing allows all sites to cross-fertilize resolutions to minimize rework, reduce the risk of repeat events, and build collective knowledge ensuring patient safety is our first commitment.