Medication errors and shift to a culture of patient leADersHiP cOluMN FEA

Medication errors and shift to a culture of patient
safety and high reliability
by Janice Chobanuk
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.
Janice Chobanuk, BScN, MN,
CHPCN(C), CON(C), Director
Ambulatory Care and Systemic
Therapy, Community Oncology,
Alberta Health Services,
CancerControl Alberta
Edmonton, Alberta
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:
costs. BMC Cancer, 111(478), 2–10.
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
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.
Shah, N.N., Casella, E., Capozzi, D.,
McGettigan, S.,
Gangadhar, T.C.,
Schuchter, L., & Myers, J.S. (2016).
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).
and children with cancer in the
outpatient setting. Journal of Clinical
Oncology, 27(6), 891–896. doi:10.1200/
Canadian Oncology Nursing Journal • Volume 26, Issue 3, Summer 2016
Revue canadienne de soins infirmiers en oncologie