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ASCO Quality Care 2017: Reduction in Chemotherapy Errors Through Improvement Science

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Key Points

  • By implementing a variety of unique interventions, the study center saw a reduction in errors from a baseline rate of 3.8 errors per 1,000 doses of chemotherapy to 1.9 per 1,000 doses 22 months into the project.
  • The error shift has been sustained for more than 4 years.
  • The key intervention was a “chemotherapy safety huddle,” where staff discussed and planned the next 24 hours of chemotherapy administration and reviewed any errors in the previous 24 hours.

The majority of children with cancer are treated with complicated chemotherapy regimens that include multiple drugs, demanding monitoring schedules and complex dosing based on body surface area that often require changes in dose. Given this high risk for error in treating children with these highly complex regiments, researchers outlined a quality improvement initiative that significantly cut chemotherapy administration errors at a large urban pediatric academic medical center. Their findings were presented and published by Weiss et al at the 2017 Quality Care Symposium (Abstract 37) and in the Journal of Oncology Practice, respectively.

The researchers from the Cincinnati Children’s Hospital Medical Center created a chemotherapy safety working group and developed an improvement program that was implemented in the spring of 2011. The researchers looked at the total number of chemotherapy (oral, intravenous, intrathecal, intramuscular, or subcutaneous) errors before and after the interventions, between January 10, 2010, and September 30, 2016.

Study Findings

During the improvement project, researchers monitored impact of the interventions and reported outcomes as errors per 1,000 doses per month. By implementing a variety of unique interventions, the study center saw a reduction in errors from a baseline rate of 3.8 errors per 1,000 doses of chemotherapy to 1.9 errors per 1,000 doses 22 months into the project—a shift that has been sustained for more than 4 years. 

The key intervention was a “chemotherapy safety huddle,” where staff discussed and planned the next 24 hours of chemotherapy administration and reviewed any errors in the previous 24 hours. The authors said that the huddle created a culture of identifying potential threats to patient safety in a nonpunitive setting.

Additional interventions included headphones for clinicians ordering chemotherapy (to reduce noise and notify others that they should not be interrupted); methods to deal with leaking chemotherapy lines; standards for chemotherapy administration throughout the hospital; an intensive care unit nurse collaboration and the development of “chemo safety zones”; and quiet areas where clinicians review and sign treatment orders.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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