scholarly journals ReCAP: Comparison of Independent Error Checks for Oral Versus Intravenous Chemotherapy

2016 ◽  
Vol 12 (2) ◽  
pp. 168-169 ◽  
Author(s):  
Melissa C. Griffin ◽  
Rachel E. Gilbert ◽  
Larry H. Broadfield ◽  
Anthony E. Easty ◽  
Patricia L. Trbovich ◽  
...  
Keyword(s):  
Patient Safety ◽  
Nova Scotia ◽  
Improve Patient Safety ◽  
Real Life ◽  
Community Pharmacists ◽  
The United States ◽  
Oral Chemotherapy ◽  
Cancer Center ◽  
Community Pharmacies ◽  
Improve Patient

QUESTION ASKED: In the United States, research has found that oral chemotherapy is subject to fewer safeguards than are in routine use for intravenous (IV) chemotherapy; however, less is known about the Canadian context. The objective of this study was to determine whether similar safeguards, in the form of independent checks, existed to identify potential errors related to IV and oral chemotherapy formulations in a particular cancer system. SUMMARY ANSWER: In the cancer system studied, a total of 57 systematic checks were identified for IV chemotherapy, whereas only six systematic checks were identified for oral chemotherapy. Community pharmacists were the only qualified professionals involved in independent, systematic checking of oral chemotherapy, which occurred during ordering and dispensing. METHODS: Human factors specialists conducted observations and interviews in cancer center clinics, a cancer center pharmacy, and four community pharmacies across Nova Scotia. Processes were analyzed to determine whether an independent check was performed, which qualified provider completed the check, and at what point of the process the check occurred. BIAS, CONFOUNDING FACTOR(S), DRAWBACKS: This study had some limitations. Although there are many forms of safeguards (eg, preprinted orders), only one type of safeguard (ie, independent checks) was examined in the cancer system studied. We chose to focus on independent checks because they were observable and were defined in the cancer center’s policies. Another limitation was that just a single jurisdiction (Nova Scotia), and four community pharmacies were examined. We examined each community pharmacy in detail, and sites were chosen to be representative (eg, rural versus urban). Further, the model used to deliver oral chemotherapy in Nova Scotia is not unique; a number of other provinces share similar models. REAL-LIFE IMPLICATIONS: There is an enormous opportunity for pharmacists and other qualified professionals to take on an expanded role in improving patient safety for oral chemotherapy. Oral chemotherapy, like IV chemotherapy, is known to be potentially hazardous, but in the cancer system studied, there were dramatically fewer independent checks associated with all aspects of oral chemotherapy–related processes. Greater involvement of pharmacists, both in the clinic environment and the community, would facilitate increased systematic checking, which could improve patient safety related to oral chemotherapy. [Figure: see text]

scholarly journals Leveraging IT to Improve Patient Safety

2003 ◽  
Vol 12 (01) ◽  
pp. 153-158
Author(s):  
D.E. Garets ◽  
T.J. Handler ◽  
M.J. Ball
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Quality Care ◽  
Quality Of Healthcare ◽  
The United States ◽  
Institute Of Medicine ◽  
The Media ◽  
The Military ◽  
Improve Patient

Abstract:Medical errors and issues of patient safety are hardly new phenomena. Even during the dawn of medicine, Hippocrates counselled new physicians “to above all else do no harm.” In the United States, efforts to improve the quality of healthcare can be seen in almost every decade of the last century. In the early 1900s, Dr. Ernest Codman failed in his efforts to get fellow surgeons to look at the outcomes of their cases. In the 1970s, there was an outcry that the military allowed an almost blind surgeon to continue to practice and even transferred him to the prestigious Walter Reed Hospital. More recently, two reports by the Institute of Medicine caught the attention of the media, the American public, and the healthcare industry. To Err Is Human highlights the need to reduce medical errors and improve patient safety, and Crossing The Quality Chasm calls for a new health system to provide quality care for the 21st century.

Errors in Laboratory Medicine: Practical Lessons to Improve Patient Safety

2005 ◽  
Vol 129 (10) ◽  
pp. 1252-1261 ◽  
Author(s):  
Peter J. Howanitz
Keyword(s):  
Patient Safety ◽  
Performance Measures ◽  
Improve Patient Safety ◽  
Clinical Pathology ◽  
The United States ◽  
Laboratory Medicine ◽  
Error Reduction ◽  
Error Rates ◽  
Patient Identification ◽  
Improve Patient

Abstract Context.—Patient safety is influenced by the frequency and seriousness of errors that occur in the health care system. Error rates in laboratory practices are collected routinely for a variety of performance measures in all clinical pathology laboratories in the United States, but a list of critical performance measures has not yet been recommended. The most extensive databases describing error rates in pathology were developed and are maintained by the College of American Pathologists (CAP). These databases include the CAP's Q-Probes and Q-Tracks programs, which provide information on error rates from more than 130 interlaboratory studies. Objectives.—To define critical performance measures in laboratory medicine, describe error rates of these measures, and provide suggestions to decrease these errors, thereby ultimately improving patient safety. Setting.—A review of experiences from Q-Probes and Q-Tracks studies supplemented with other studies cited in the literature. Design.—Q-Probes studies are carried out as time-limited studies lasting 1 to 4 months and have been conducted since 1989. In contrast, Q-Tracks investigations are ongoing studies performed on a yearly basis and have been conducted only since 1998. Participants from institutions throughout the world simultaneously conducted these studies according to specified scientific designs. The CAP has collected and summarized data for participants about these performance measures, including the significance of errors, the magnitude of error rates, tactics for error reduction, and willingness to implement each of these performance measures. Main Outcome Measures.—A list of recommended performance measures, the frequency of errors when these performance measures were studied, and suggestions to improve patient safety by reducing these errors. Results.—Error rates for preanalytic and postanalytic performance measures were higher than for analytic measures. Eight performance measures were identified, including customer satisfaction, test turnaround times, patient identification, specimen acceptability, proficiency testing, critical value reporting, blood product wastage, and blood culture contamination. Error rate benchmarks for these performance measures were cited and recommendations for improving patient safety presented. Conclusions.—Not only has each of the 8 performance measures proven practical, useful, and important for patient care, taken together, they also fulfill regulatory requirements. All laboratories should consider implementing these performance measures and standardizing their own scientific designs, data analysis, and error reduction strategies according to findings from these published studies.

scholarly journals Evaluating Patient Safety Culture in Iraqi Community Pharmacies

2021 ◽  
Vol 30 (1) ◽  
pp. 154-162
Author(s):  
Basma S. Jasim ◽  
Mohammed Y. Jamal
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Health Care Organization ◽  
Patient Safety Culture ◽  
Healthcare Research ◽  
Community Pharmacies ◽  
Care Organization ◽  
Patient Counseling ◽  
Work Pressure ◽  
Improve Patient

Patient safety is the main issue in health care organization, the Agency for Healthcare Research and Quality defines it as, “freedom from accidental or preventable injuries produced by medical care. Thus, practices or interventions that improve patient safety are those that reduce the occurrence of preventable adverse events”. The purpose of this study was to evaluate Iraqi pharmacist perception about the culture of patient safety. As well as estimate whether safety is a principal issue in their pharmaceutical practice this study was carried out on 435 pharmacists who are working in community pharmacies in various Iraqi provinces. A survey was distributed via the internet during the period from May to June 2020. A community pharmacy questionnaire was used to evaluate the awareness of pharmacists regarding the culture of patient safety. A result of this study shows that the patient counseling field was the most positive one  among the studied domains with score 68.8%  of positive awareness and 70.4% of the pharmacists indicated that they inform patients with needed information about their new prescriptions.  In contrast, staffing and work pressure scored the lowest positive response (36.55%). Although 66.7% of the participants stated they have the appropriate number of staff in their pharmacies to deal with the workload.

Using simulation exercises to improve student skills and patient safety

2021 ◽  
Vol 30 (20) ◽  
pp. 1198-1202
Author(s):  
Aby Mitchell ◽  
Georgiana Assadi
Keyword(s):  
Higher Education ◽  
Patient Safety ◽  
Workforce Development ◽  
Improve Patient Safety ◽  
Real Life ◽  
Nurse Education ◽  
Immersive Learning ◽  
Nursing Training ◽  
Improve Patient ◽  
Simulation Exercises

The COVID-19 pandemic has affected the delivery of nursing training in higher education and how workforce development programmes are delivered. Using simulated practice is an opportunity for experiential and immersive learning in a safe and supported environment that replaces real life. This article discusses the use of simulation in nurse education to improve patient safety.

Standardization of oral chemotherapy delivery to improve patient safety: A pilot study.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 90-90
Author(s):  
Tejas Desai ◽  
Maritza Carvalho ◽  
Ron Fung ◽  
Devi Ahuja ◽  
Simerjit Gollee ◽  
...  
Keyword(s):  
Patient Safety ◽  
Patient Adherence ◽  
Care Pathway ◽  
Improve Patient Safety ◽  
Treatment Plan ◽  
Oral Chemotherapy ◽  
Safety Standards ◽  
Patient Safety Indicators ◽  
Improve Patient ◽  
Pharmacy Interventions

90 Background: Oral chemotherapy (OC) presents unique challenges to patient safety. In contrast with parenteral chemotherapy, patient education and comprehension are crucial to the safe administration of OC, appropriate toxicity interventions and patient adherence. At Trillium Health Partners we identified a lack of standardization to OC education and monitoring, that resulted in gaps in patient care. Using the American Society of Clinical Oncology/Oncology Nursing Society 2013 chemotherapy safety standards as guidance, we developed and piloted a multi-disciplinary oral chemotherapy care pathway (OCCP) to improve the approach to education and monitoring of patients newly started on OC. Methods: Patients newly started on OC between 03/15–06/15 were enrolled by 2 participating physicians representing a predominantly lung/GI practice. Baseline data was abstracted retrospectively in the 3 months prior to the pilot to reflect all study participants. The OCCP included in-person and telephone assessments by an oncology pharmacist and nurse over 2 cycles of OC. Pilot outcomes included pharmacy interventions, dose modification for toxicity, medication errors, the percent of prescriptions on computerized physician order entry (CPOE), adherence documentation and comprehension of treatment plan. Results: The pilot enrolled 20 patients and compared them against 21 baseline patients. During the pilot there were improvements in the percentage of patients who had pharmacy interventions, documentation of adherence and assessment of comprehension of the treatment plan as well as a reduction in dose modifications due to toxicity (Table 1). Conclusions: Use of a newly developed oral chemotherapy care pathway demonstrated both feasibility as well as improvements in a variety of key patient safety indicators. These results suggest that implementation of a standardized oral chemotherapy care pathway can feasibly improve patient safety outcomes. [Table: see text]

scholarly journals Writing’s on the wall: improving the WHO Surgical Safety Checklist

2021 ◽  
Vol 10 (1) ◽  
pp. e001086
Author(s):  
Claire Cushley ◽  
Tom Knight ◽  
Helen Murray ◽  
Lawrence Kidd
Keyword(s):  
Patient Safety ◽  
Online Survey ◽  
Improve Patient Safety ◽  
Surgical Safety Checklist ◽  
Surgical Safety ◽  
Time Out ◽  
Mandatory Requirement ◽  
Who Checklist ◽  
Improve Patient ◽  
Theatre Team

Background and problemThe WHO Surgical Safety Checklist has been shown to improve patient safety as well as improving teamwork and communication in theatres. In 2009, it was made a mandatory requirement for all NHS hospitals in England and Wales. The WHO checklist is intended to be adapted to suit local settings and was modified for use in Gloucestershire Hospitals NHS Foundation Trust. In 2018, it was decided to review the use of the adapted WHO checklist and determine whether improvements in compliance and engagement could be achieved.AimThe aim was to achieve 90% compliance and engagement with the WHO Surgical Safety Checklist by April 2019.MethodsIn April 2018, a prospective observational audit and online survey took place. The results showed compliance for the ‘Sign In’ section of the checklist was 55% and for the ‘Time Out’ section was 91%. Engagement by the entire theatre team was measured at 58%. It was proposed to move from a paper checklist to a wall-mounted checklist, to review and refine the items in the checklist and to change the timing of ‘Time Out’ to ensure it was done immediately prior to knife-to-skin.ResultsFollowing its introduction in September 2018, the new wall-mounted checklist was reaudited. Compliance improved to 91% for ‘Sign In’ and to 94% for ‘Time Out’. Engagement by the entire theatre team was achieved 100% of the time. Feedback was collected, adjustments made and the new checklist was rolled out in stages across all theatres. A reaudit in December 2018 showed compliance improved further, to 99% with ‘Sign In’ and to 100% with ‘Time Out’. Engagement was maintained at 100%.ConclusionsThe aim of the project was met and exceeded. Since April 2019, the new checklist is being used across all theatres in the Trust.

scholarly journals Understanding safety in healthcare: the system evolution, erosion and enhancement model

2013 ◽  
Vol 2 (3) ◽  
pp. 25 ◽  
Author(s):  
Jane Carthey
Keyword(s):  
Patient Safety ◽  
Complex Systems ◽  
Human Error ◽  
Improve Patient Safety ◽  
New Model ◽  
System Evolution ◽  
Accident Causation ◽  
System Migration ◽  
Improve Patient

The paper summarises previous theories of accident causation, human error, foresight, resilience and system migration. Five lessons from these theories are used as the foundation for a new model which describes how patient safety emerges in complex systems like healthcare: the System Evolution Erosion and Enhancement model. It is concluded that to improve patient safety, healthcare organisations need to understand how system evolution both enhances and erodes patient safety.

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