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

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Canadian OnCOlOgy nursing JOurnal • VOlume 26, issue 3, summer 2016
reVue Canadienne de sOins infirmiers en OnCOlOgie
FEATURES/RUbRiqUES
leADersHiP cOluMN
Medication errors and shift to a culture of patient
safety and high reliability
by Janice Chobanuk
Medication errors with antineoplastic
drugs can be disastrous to patients
due to the drugs’ high toxicity and lim-
ited 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 pre-
scriptions, the researchers found an error
rate of 5.2% (449). The highest errors
were prescription errors (91%), followed
with pharmaceutical (8%) and adminis-
tration errors (1%). The researchers esti-
mated that 13.4% of these errors would
have resulted in a patient injury, 2.6%
in permanent damage, and 2.6% would
have aected 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 pediat-
ric 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.
Nursing leaders are actively promot-
ing transition to a patient safety and
high-reliability culture in order to
enhance patient safety in oncology set-
tings (Ranchon etal., 2012). This para-
digm shift requires strong leadership
support, the use of principles of high
reliability and a patient-centric focus,
as well as continuous quality improve-
ment initiatives. The strategy involves
leaders addressing issues such as inher-
ent weaknesses in processes in the can-
cer setting, clinical designs of buildings,
the impact of computer programs, sta-
ing levels, equipment issues, and other
factors that inuence 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 sys-
tem-wide preventative approach.
Globally, leaders in health care facilities
are starting to incorporate the exper-
tise and lessons learned from high-
risk groups with low failure rates, such
as aviation and nuclear power plants,
into their safety strategic approach
(Ranchon et al., 2012). These organiza-
tions 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 recog-
nize as a high-risk activity. Mistakes can
occur any time and at any stage in the
process—from the prescription, prepa-
ration, and dispensing to the adminis-
tration. The increasing number of oral
chemotherapy agents adds a new chal-
lenge for oncology facilities. Shah et al.
(2016) reported that 22 interventions
(35%) were required to prevent poten-
tial errors in 63 oral medication orders
over a seven-month period. Most of the
errors were related to dosage adjust-
ment, the identication 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 tech-
nology, 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-en-
try systems with decision support, and
smart pump technology. Oncology nurs-
ing leaders need to be actively engaged
in patient safety improvement to impact
on patients, employees, physicians, and
other clinicians in the organization.
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
Ranchon, L., McEachan, R.C., Giles, S.J.,
Sirriyeh, R., Watt, I.S., & Wright, J.
(2012). Development of an evidence-
based 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
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