Medication errors and shift to a culture of patient safety and high reliability by Janice Chobanuk M edication errors with antineoplastic drugs can be disastrous to patients due to the drugs’ high toxicity and limited therapeutic index. Cancer patients often require numerous complex and often toxic therapies for treatment, which requires careful coordination of care. In a study involving 6,607 antineoplastic prescriptions, the researchers found an error rate of 5.2% (449). The highest errors were prescription errors (91%), followed with pharmaceutical (8%) and administration errors (1%). The researchers estimated that 13.4% of these errors would have resulted in a patient injury, 2.6% in permanent damage, and 2.6% would have affected the prognosis of the cancer patient. Gandhi et al. (2005) found the chemotherapy error rate was 3% in 3,200 chemotherapy orders for adult and pediatric patients. In a study involving pediatric and adult oncology patients, the authors found chemotherapy errors were 0.3 to 5.8 per 100 visits (Walsh et al., 2009). Many oncology-nursing leaders are recognizing the importance of treating chemotherapy as a high-risk activity. ABOUT THE Author Janice Chobanuk, BScN, MN, CHPCN(C), CON(C), Director Ambulatory Care and Systemic Therapy, Community Oncology, Alberta Health Services, CancerControl Alberta Edmonton, Alberta REFERENCES Gandhi, T.K., Bartel, S.B., Shulman, L.N., Verrier, D., Burdick, E., Cleary, A., … Bates, D.W. (2005). Medication safety in the ambulatory chemotherapy setting. Cancer, 104, 2477–2483. doi:10.1002/cncr.21442 Ranchon, F., Salles, G., Späth, H., Schwiertz, V., Vantard, N., Parat, S., … Rioufol, C. (2011). Chemotherapeutic errors in hospitalised cancer patients: Attributable damage and extra costs. BMC Cancer, 111(478), 2–10. doi:10.1186/1471-2407-11-478 Nursing leaders are actively promoting transition to a patient safety and high-reliability culture in order to enhance patient safety in oncology settings (Ranchon et al., 2012). This paradigm shift requires strong leadership support, the use of principles of high reliability and a patient-centric focus, as well as continuous quality improvement initiatives. The strategy involves leaders addressing issues such as inherent weaknesses in processes in the cancer setting, clinical designs of buildings, the impact of computer programs, staffing levels, equipment issues, and other factors that influence the local working conditions. A focus on safety requires oncology leaders to move away from reactive responses to error reports, and reviewing individual actions and the error, to embrace a proactive system-wide preventative approach. Globally, leaders in health care facilities are starting to incorporate the expertise and lessons learned from highrisk groups with low failure rates, such as aviation and nuclear power plants, into their safety strategic approach (Ranchon et al., 2012). These organizations have developed an array of tools for assessing organizational factors that have the potential to lead to a failure or error. The tools address issues such as supervision, planning, communication, training, and maintenance. Instead of a retrospective analysis of adverse events, these tools enable oncology leaders to transition to a more proactive culture of patient safety and monitor safety trends in the organization on a continual basis. Chemotherapy management is a hazardous and challenging procedure that oncology leaders need to recognize as a high-risk activity. Mistakes can occur any time and at any stage in the process—from the prescription, preparation, and dispensing to the administration. The increasing number of oral chemotherapy agents adds a new challenge for oncology facilities. Shah et al. (2016) reported that 22 interventions (35%) were required to prevent potential errors in 63 oral medication orders over a seven-month period. Most of the errors were related to dosage adjustment, the identification of interacting drugs, and additional drug monitoring. Oncology nursing leaders are well positioned to drive a culture shift to patient safety and high reliability. This change involves tactical strategies such as education, safety committees, safety protocols and procedures, use of technology, a no blame atmosphere, and a focus on zero medication errors (Ranchon, McEachan, Giles, Sirriyeh, Watt, & Wright, 2012). Other examples of initiatives include independent double checks, bar codes, electronic order-entry systems with decision support, and smart pump technology. Oncology nursing leaders need to be actively engaged in patient safety improvement to impact on patients, employees, physicians, and other clinicians in the organization. Ranchon, L., McEachan, R.C., Giles, S.J., Sirriyeh, R., Watt, I.S., & Wright, J. (2012). Development of an evidencebased framework of factors contributing to patient safety incidents in hospital settings: A systematic review. BMJ Quality and Safety, 21(5), 369–380. doi:10.1136/bmjqs-2011-000443 Shah, N.N., Casella, E., Capozzi, D., McGettigan, S., Gangadhar, T.C., Schuchter, L., & Myers, J.S. (2016). Improving the safety of oral chemotherapy at an academic medical center. Journal of Oncology Practice, 12(1), 71–76. doi:10.1200/JOP.2015.007260 Walsh, K.E., Dodd, K.S., Seetharaman, K., Roblin, D.W., Herrinton, L.J., Worley, A.V., … Gurwitz, J.H. (2009). Medication errors among adults and children with cancer in the outpatient setting. Journal of Clinical Oncology, 27(6), 891–896. doi:10.1200/ JCO.2008.18.6072 Canadian Oncology Nursing Journal • Volume 26, Issue 3, Summer 2016 Revue canadienne de soins infirmiers en oncologie 255 FEATURES/Rubriques LEADERSHIP COLUMN