Risk Factors for Adverse Events in Patients With Breast, Colorectal, and Lung Cancer.

OBJECTIVE: The aim of the study was to identify risk factors associated with medical errors and iatrogenic injuries during an initial course of cancer-directed treatment. METHODS: In this retrospective cohort study of 400 patients 18 years or older undergoing an initial course of treatment for breast, colorectal, or lung cancer at a comprehensive cancer center, we abstracted patient, disease, and treatment-related variables from the electronic medical record. We examined adverse events (AEs) and preventable AEs by risk factor using the χ2 or Fisher exact tests. We estimated the association between risk factors and the relative risk of an additional AE or preventable AE in multivariable negative binomial regression models with backwards selection (P < 0.1). RESULTS: There were 304 AEs affecting 136 patients (34%) and 97 preventable AEs affecting 53 patients (13%). In multivariable analyses, AEs were overrepresented in those with lung cancer compared with patients with breast cancer (incident rate ratio = 1.9, 95% confidence interval = 1.1-3.2). Nonwhite race (1.6, 1.0-2.6), Hispanic or Latino ethnicity (2.0, 0.9-4.1), advanced disease (1.7, 1.1-2.6), use of each additional class of high-risk nonchemotherapy medication (1.6, 1.3-1.9), and chemotherapy (2.1, 1.3-3.3) were all associated with risk of an additional AE. Preventable AEs were associated with lung cancer (7.4, 2.4-23.2), Hispanic or Latino ethnicity (5.5, 1.7-17.9), and high-risk nonchemotherapy medications (1.5, 1.2-2.0). CONCLUSIONS: Risk factors for AEs among patients with cancer reflected patients' underlying disease, cancer-directed therapy, and high-risk noncancer medications. The association of AEs with ethnicity merits further research. Risk factor models could be used prospectively to identify patients with cancer at increased risk of harm.

A Communication Training Program to Encourage Speaking-Up Behavior in Surgical Oncology.

Patient safety in the OR depends on effective communication. We developed and tested a communication training program for surgical oncology staff members to increase communication about patient safety concerns. In phase one, 34 staff members participated in focus groups to identify and rank factors that affect speaking-up behavior. We compiled ranked items into thematic categories that included role relations and hierarchy, staff rapport, perceived competence, perceived efficacy of speaking up, staff personality, fear of retaliation, institutional regulations, and time pressure. We then developed a communication training program that 42 participants completed during phase two. Participants offered favorable ratings of the usefulness and perceived effect of the training. Participants reported significant improvement in communicating patient safety concerns (t40 = -2.76, P = .009, d = 0.48). Findings offer insight into communication challenges experienced by surgical oncology staff members and suggest that our training demonstrates the potential to improve team communication.

Preventable and mitigable adverse events in cancer care: Measuring risk and harm across the continuum.

BACKGROUND: Patient safety is a critical concern in clinical oncology, but the ability to measure adverse events (AEs) across cancer care is limited by a narrow focus on treatment-related toxicities. The objective of this study was to assess the nature and extent of AEs among cancer patients across inpatient and outpatient settings. METHODS: This was a retrospective cohort study of 400 adult patients selected by stratified random sampling who had breast (n = 128), colorectal (n = 136), or lung cancer (n = 136) treated at a comprehensive cancer center in 2012. Candidate AEs, or injuries due to medical care, were identified by trained nurse reviewers over the course of 1 year from medical records and safety-reporting databases. Physicians determined the AE harm severity and the likelihood of preventability and harm mitigation. RESULTS: The 400-patient sample represented 133,358 days of follow-up. Three hundred four AEs were identified for an overall rate of 2.3 events per 1000 patient days (91.2 per 1000 inpatient days and 0.9 per 1000 outpatient days). Thirty-four percent of the patients had 1 or more AEs (95% confidence interval, 29%-39%), and 16% of the patients had 1 or more preventable or mitigable AEs (95% confidence interval, 13%-20%). The AE rate for patients with breast cancer was lower than the rate for patients with colorectal or lung cancer (P ≤ .001). The preventable or mitigable AE rate was 0.9 per 1000 patient days. Six percent of AEs and 4% of preventable AEs resulted in serious harm. Examples included lymphedema, abscess, and renal failure. CONCLUSIONS: A heavy burden of AEs, including preventable or mitigable events, has been identified. Future research should examine risk factors and improvement strategies for reducing their burden. Cancer 2017;123:4728-4736. © 2017 American Cancer Society.

Performance of a Trigger Tool for Identifying Adverse Events in Oncology.

PURPOSE: Although patient safety is a priority in oncology, few tools measure adverse events (AEs) beyond treatment-related toxicities. The study objective was to assemble a set of clinical triggers in the medical record and assess the extent to which triggered events identified AEs. METHODS: We performed a retrospective cohort study to assess the performance of an oncology medical record screening tool at a comprehensive cancer center. The study cohort included 400 patients age 18 years or older diagnosed with breast (n = 128), colorectal (n = 136), or lung cancer (n = 136), observed as in- and outpatients for up to 1 year. RESULTS: We identified 790 triggers, or 1.98 triggers per patient (range, zero to 18 triggers). Three hundred four unique AEs were identified from medical record reviews and existing AE databases. The overall positive predictive value (PPV) of the original tool was 0.40 for total AEs and 0.15 for preventable or mitigable AEs. Examples of high-performing triggers included return to the operating room or interventional radiology within 30 days of surgery (PPV, 0.88 and 0.38 for total and preventable or mitigable AEs, respectively) and elevated blood glucose (> 250 mg/dL; PPV, 0.47 and 0.40 for total and preventable or mitigable AEs, respectively). The final modified tool included 49 triggers, with an overall PPV of 0.48 for total AEs and 0.18 for preventable or mitigable AEs. CONCLUSION: A valid medical record screening tool for AEs in oncology could offer a powerful new method for measuring and improving cancer care quality. Future improvements could optimize the tool's efficiency and create automated electronic triggers for use in real-time AE detection and mitigation algorithms.

ReCAP: Detection of Potentially Avoidable Harm in Oncology From Patient Medical Records.

PURPOSE: Widespread consensus exists about the importance of addressing patient safety issues in oncology, yet our understanding of the frequency, spectrum, and preventability of adverse events (AEs) across cancer care is limited. METHODS: We developed a screening tool to detect AEs across cancer care settings through medical record review. Members of the study team reviewed the scientific literature and obtained structured input from an external multidisciplinary panel of clinicians by using a modified Delphi process. RESULTS: The screening tool comprises 76 triggers-readily identifiable findings to screen for possible AEs that occur during cancer care. Categories of triggers are general care, vital signs, medication related, laboratory tests, other orders, and consultations. CONCLUSION: Although additional testing is required to assess its performance characteristics, this tool may offer an efficient mechanism for identifying possibly preventable AEs in oncology and serve as an instrument for quality improvement.

The impact of new technologies on radiation oncology events and trends in the past decade: an institutional experience.

PURPOSE: To review the type and frequency of patient events from external-beam radiotherapy over a time period sufficiently long to encompass significant technology changes. METHODS AND MATERIALS: Ten years of quality assurance records from January 2001 through December 2010 were retrospectively reviewed to determine the frequency of events affecting patient treatment from four radiation oncology process steps: simulation, treatment planning, data entry/transfer, and treatment delivery. Patient events were obtained from manual records and, from May 2007 onward, from an institution-wide database and reporting system. Events were classified according to process step of origination and segregated according to the most frequently observed event types. Events from the institution-wide database were evaluated to determine time trends. RESULTS: The overall event rate was 0.93% per course of treatment, with a downward trend over time led by a decrease in treatment delivery events. The frequency of certain event types, particularly in planning and treatment delivery, changed significantly over the course of the study, reflecting technologic and process changes. Treatments involving some form of manual intervention carried an event risk four times higher than those relying heavily on computer-aided design and delivery. CONCLUSIONS: Although the overall event rate was low, areas for improvement were identified, including manual calculations and data entry, late-day treatments, and staff overreliance on computer systems. Reducing the incidence of pretreatment events is of particular importance because these were more likely to occur several times before detection and were associated with larger dosimetric impact. Further improvements in quality assurance systems and reporting are imperative, given the advent of electronic charting, increasing reliance on computer systems, and the potentially severe consequences that can arise from mistakes involving complex intensity-modulated or image-guided treatments.

Analysis and prioritization of near-miss adverse events in a radiology department.

OBJECTIVE: The purpose of this study is to describe a method for the evaluation and prioritization of near-miss events in a radiology department. MATERIALS AND METHODS: Sixty-two consecutive near-miss events occurring between 2007 and 2009 were retrospectively evaluated, classified by error type, and scored for five elements associated with risk. The worst outcome potentially associated with each event was predicted by consensus and scored on a standardized 5-point complications grading scale. Scores were then assigned for event frequency, method of detection, barrier number, and quality. The product of individual scores, ranging from 1 to 180, was termed the hazard score. Events were analyzed by error type, element scores, and hazard score. RESULTS: Electronic order entry errors were the most common error type, and 90% of these errors originated outside the radiology department. More than half (65%) of the events were assigned maximal severity scores, and 68% of the errors had been encountered three or more times previously. Twenty-five events (40%) were detected by good fortune rather than by plan. No barrier to the projected worst outcome was identified in nearly half (47%) of cases. In most instances (73%), strong barriers were absent. Nine events (15%) had maximal hazard scores of 180, whereas 21 events (34%) had hazard scores of 30 or less. CONCLUSION: This method was constructed from standardized definitions of outcome severity, the ability of current systems to detect or mitigate an adverse event or outcome, and event frequency and offers a tool for systematic evaluation and stratification of near-miss adverse events.

The perceived value of certification by certified perioperative nurses.

We conducted this study to determine the perceived value of certification in perioperative nursing. Following development and pilot-testing, we mailed the 18-item Likert-type instrument, the Perceived Value of Certification Tool (PVCT), to a sample of 2750 perioperative nurses who had earned the CNOR or CRNFA credential or both. A total of 1398 surveys were returned (50.8% response rate). Factor analysis extracted three factors, accounting for 61% of the variance: personal value, recognition by others, and professional practice. Internal consistency reliability testing (Cronbach's alpha) identified a standardized alpha of.924. Over 90% of respondents agreed or strongly agreed with statements about the value of certification related to feelings of personal accomplishment and satisfaction, validating specialized knowledge, indicating professional growth, attainment of a practice standard, personal challenge, and professional commitment, challenge, and credibility. These results are consistent with previously published literature on specialty certification in nursing.

Stories from the operating room: moral dilemmas for nurses.

This article explores stories related by perioperative nurses when asked to describe ethical judgements and subsequent actions that affected patient outcomes. A total of 214 patient care situations were analysed for moral actions taken and moral outcomes achieved in the perioperative arena. Content analysis of the patient care situations revealed a wide variety of ethical issues. Concerns about informed consent and quality of care were the most frequently identified issues. Respondents reported that 7% of patients underwent unwanted procedures and that positive moral outcomes were achieved in 65% of situations. It is of concern that, despite the fact that more than two-thirds (69%) of the respondents reported undergoing ethics education, only 27% could relate a story of an ethical situation.

Morality in perioperative nurses.

This study examined nurses' moral motivation, character, and action using a Model of Morality for Perioperative Nurses. Influences on moral actions and selected outcomes for surgical patients and perioperative nurses were examined. Results indicate that motivation and character are related directly to the moral actions of perioperative nurses (R = .13 to .31, P < .001). Fourteen percent of the variance in action was explained by motivation, character, self-perceived level of practice, and ethics education. Results suggest that current models do not describe the moral behavior of perioperative nurses adequately. Future research should examine constructs that explain the moral actions of nurses in the perioperative setting.