Improving Chemotherapy Delivery* and Transfusion Safety

1
Improving Chemotherapy Delivery and Transfusion
Safety

• Vanderbilt University Medical Center
• BlueCross BlueShield of Tennessee
• October 2, 2001

2
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

3
Why Do Errors Occur?

• 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!

4
Patient Safety at VUMC

• Blood Transfusion Safety
• MRI Safety
• Westchester Medical Center, Valhalla, NY
• Chemotherapy Delivery
• Dana Farber Cancer Institute, Boston

5
Transfusion Safety

• Major Processes of Transfusion System
• Ordering blood (Verbal, written, order entry)
• Handling/Storage of blood
• Transfusion of product into patient
• Safety Concerns
• Communications
• Patient identification (Patient-product match)
• Workload/Stress
• Blood handling

6
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.

7
Metrics - Across Chemo Delivery

• Prescriptions - Physician
• Processing - Pharmacy
• Administration - Nursing

8
Metrics - Chemo Delivery Processes

• Prescribing Processing Administration
• Correct Drug
• Correct Dose
• Correct Route
• Correct Schedule
• Omission
• Allergy
• Contra Indications
• Monitoring

Patient in need
9
Errors and Near Misses
10
Reducing Chemo Errors

• 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

11
Proposed System

• Perfect chemotherapy delivery
• Chemotherapy Intelligent Delivery System (ChIDS)
• Blame-free reporting
• Essential System Characteristics
• Uses available technologies
• Real-time data
• Feedback providing (closing the loop)
• Designed to succeed (safe)

12
Intelligent Delivery System
13
Reporting Improvement
Baseline
Implementation
8
7
6
5
Near misses reported
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
14
Pediatric Oncology Pilot Registry
15
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