Perfecting Chemotherapy Delivery

Report
Improving Chemotherapy Delivery*
and Transfusion Safety
Vanderbilt University Medical Center
*BlueCross BlueShield of Tennessee
October 2, 2001
Motivation
• Institute of Medicine (IOM) report - Nov 1999
• IOM Recommendations
– “Establishment of voluntary reporting system to
collect information on errors that cause minimal or
no harm”
– Build a culture of safety
Why Do Errors Occur?
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Complexity – how much info can our minds process?
Hand-offs and and shift changes
Verbal and written communications
Look-alikes and sound-alikes
Stressful situations/Understaffing
Poor system designs and unsafe situations
We are human!
Patient Safety at VUMC
• Blood Transfusion Safety
• MRI Safety
– Westchester Medical Center, Valhalla, NY
• Chemotherapy Delivery
– Dana Farber Cancer Institute, Boston
Transfusion Safety
• Major Processes of Transfusion System
– Ordering blood (Verbal, written, order entry)
– Handling/Storage of blood
– Transfusion of product into patient
• Safety Concerns
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Communications
Patient identification (Patient-product match)
Workload/Stress
Blood handling
Chemotherapy Project Overview
• Project Aim
– Guarantee safe and appropriate chemotherapy
delivery to each and every pediatric oncology
patient
• Outcomes Focus
– To eliminate adverse drug events (ADEs) /
outcomes associated with variation chemotherapy
delivery
• Process Focus
– Improve the system processes for prescribing,
processing, and administration of chemotherapy.
Metrics - Across Chemo Delivery
Prescriptions - Physician
Processing - Pharmacy
Administration - Nursing
Metrics - Chemo Delivery Processes
Prescribing
Correct Drug
Correct Dose
Correct Route
Correct Schedule
Omission
Allergy
Contra Indications
Monitoring
Processing
Administration
Patient in need
Errors and “Near Misses”
Reducing Chemo Errors
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Certified healthcare providers only (Onc/chemo)
Verify the dose via dose-verification process
Establish dosage limits
Standardize the prescribing vocabulary
Work with drug manufacturers – improve labeling
safety
• Educate the patients about their chemo meds
• Improve communication through use of
multidisciplinary teams
Proposed System
Perfect chemotherapy delivery
– Chemotherapy Intelligent Delivery System (ChIDS)
– Blame-free reporting
Essential System Characteristics
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Uses available technologies
Real-time data
Feedback providing (closing the loop)
Designed to succeed (safe)
Intelligent Delivery System
Decision Support System
Blame-Free ADE Reporting
(Inbedded saf ety logic)
(Process f ocused)
Perfect Chemotherapy Delivery
Clinical Improvement
(generate hypotheses, tests of change)
Chemotherapy Registry
(tracks metrics over time)
Reporting Improvement
Near misses reported
8
Baseline
Implementation
7
6
5
4
3
2
1
0
-23 -21 -19 -17 -15 -13 -11
-9
-7
-5
-3
-1
1
3
5
7
9
11
13 15 17
Month relative to blame-free reporting implementation
Pediatric Oncology Pilot Registry
Clinical Improvement
• Performance measures - rates of occurrences and time
between occurrences (rare events)
• Data plotted over time using statistical process control
(SPC) charts
• Quality improvement (QI) techniques used to drill
down to root causes of variability in chemo delivery
• Understanding of process variation used to improve
delivery system through rapid tests of change
• Improve outcomes

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