Congress Abstracts 2004

6

MEASURING THE SUCCESS OF CHEMOTHERAPY SAFETY INTERVENTIONS: A QUALITY IMPROVEMENT INITIATIVE. Mikaela Olsen RN, MS, OCN^®, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.

The ultimate goal of oncology providers is to ensure an environment free of chemotherapy errors. This designated comprehensive cancer center was faced with serious chemotherapy errors related to inconsistent practices within the system and among providers. Using the Plan, Do, Study, Act Process, numerous safety changes related to the chemotherapy processes of prescribing, dispensing, and administering were implemented. This process resulted in a revised chemotherapy policy, which included many new safety requirements, the addition of a chemotherapy treatment note, the creation of a pre-chemotherapy administration checklist, the development of standard pre-printed chemotherapy orders, and monthly multidisciplinary updates and discussions regarding errors. These safety changes proved to be highly successful in decreasing the number of chemotherapy errors that reach our cancer patients.

While chemotherapy errors reaching the patient have decreased in this institution, new practice challenges have emerged, such as ongoing education of new and existing staff, maintenance of staff compliance and diligence with the completion of required chemotherapy safety checks, and unanticipated chemotherapy errors.

Outcome measures were put into place to monitor the existing process. Using a novel web-based intranet data collection tool, charts are retrospectively audited by trained oncology staff within 72 hours of chemotherapy administration. The ease of use of this audit tool and the ability to instantly analyze and generate reports ensures that sufficient numbers of charts can be audited and problems in the chemotherapy process identified and trended in a timely manner.

Specific measures yield data regarding staff compliance and knowledge related to chemotherapy safety requirements and actual and near-miss errors.

This presentation will highlight and review specific outcome measures utilized to monitor the success of chemotherapy safety interventions implemented. It will also describe how the results of this on-line audit can lead to further changes in chemotherapy procedures, education of staff, and provide data for a more analytical review of potential errors using Failure Modes Effect Analysis (FMEA), and actual errors using Root Cause Analysis (RCA)