Standardizing central venous catheter care by using observations from patients with cancer.

To understand the vulnerability of patients with cancer to central line-associated bloodstream infections related to tunneled central venous catheters (CVCs), patients were asked to describe their line care at home and in clinic and to characterize their knowledge and experience managing CVCs. Forty-five adult patients with cancer were recruited to participate. Patients were interviewed about the type of line, duration of use, and observations of variations in line care. They also were asked about differences between line care at home and in the clinic, precautions taken when bathing, and their education regarding line care. Demographic information and primary cancer diagnosis were taken from the patients' medical records. Patients with hematologic and gastrointestinal malignancies were heavily represented. The majority had tunneled catheters with subcutaneous implanted ports. Participants identified variations in practice among nurses who cared for them. Although many participants expressed confidence in their knowledge of line care, some were uncertain about what to do if the dressing became loose or wet, or how to recognize an infection. Patients seemed to be astute observers of their own care and offered insights into practice variation. Their observations show that CVC care practices should be standardized, and educational interventions should be created to address patients' knowledge deficits.

Comparing clinicians' use of an anticoagulation management service and usual care in ambulatory oncology.

PURPOSE: There is no consensus in the oncology community about the optimal model for anticoagulation management of ambulatory cancer patients. To understand oncologists' preferences regarding anticoagulation management, we compared the characteristics of patients referred to an oncology-oriented anticoagulation management service with "usual care" patients managed by the patient's primary oncologist. METHODS: We performed a retrospective medical record review of ambulatory oncology patients' anticoagulation care at a comprehensive cancer center. We examined the characteristics of 33 patients anticoagulated before implementation of a dedicated oncology anticoagulation management service. We compared this group with 33 patients managed by the anticoagulation management service and with 39 usual care patients managed by the primary oncologist after the anticoagulation management service was created. We also examined differences in laboratory test utilization, time in the therapeutic range (for patients anticoagulated with warfarin), and anticoagulation-related adverse events during a 3-month assessment period. RESULTS: Anticoagulation management service patients were more likely to be treated for hematologic malignancies, use erythropoietin stimulating agents, and require warfarin management for previous venous thromboembolic disease compared to usual care patients. In contrast, oncologists were more likely to manage anticoagulation care of patients with advanced solid tumors undergoing active chemotherapy. Anticoagulation management service and usual care patients on warfarin therapy had comparable time in the therapeutic range and complication rates. CONCLUSION: Oncologists selectively referred patients to the anticoagulation management service. Anticoagulation management service patients' warfarin control and complication rates were comparable to care provided by the primary oncologist, suggesting that an oncology-specific anticoagulation management service may be a feasible and effective option for anticoagulation management of ambulatory oncology patients.

Assessing the quality of pain care in ambulatory patients with advanced stage cancer.

CONTEXT: Pain is common among patients with advanced cancer despite the dissemination of clinical pain care guidelines. OBJECTIVES: We sought to assess the quality of pain care among patients with advanced disease. METHODS: We reviewed the records of 85 adult ambulatory patients with advanced breast, lung, and gastrointestinal cancer treated in 2004-2006. Patients' screening pain intensity scores were at least 7 of 10. Nurse reviewers completed medical record reviews of care rendered at the index visit and over the subsequent 30 days based on the 2004 National Comprehensive Cancer Network pain guideline. An expert panel then rated the quality of the evaluation, treatment, and overall pain care. We used a multivariable model to analyze guideline compliance and resolution of severe pain. RESULTS: Among advanced cancer patients with severe pain, clinicians adjusted pain medications only half the time and made few timely referrals for pain-related consultations. By 30 days after the index visit, 34% of patients continued to report severe pain. The expert panel judged the overall quality of pain care as "fair" or "poor" in about two-thirds of cases because more timely and effective intervention could have reduced the severity and duration of pain. Resolution of severe pain was associated with adjustment of pain medications at the index visit (adjusted odds ratio 3.8, 95% CI 1.3-10.6). CONCLUSION: There is room for improvement in the pain care of patients with advanced cancer. Additional research is needed to understand the reasons for poor performance.

Rating recommendations for consumers about patient safety: sense, common sense, or nonsense?

BACKGROUND: Although many organizations offer advice about the consumer's role in improving patient safety, little is known about these recommendations. METHODS: The Internet and medical literature were searched to identify patient safety recommendations for consumers. Recommendations were classified by type and tabulated by frequency. Nine investigators rated each recommendation for the quality of supporting empirical evidence, magnitude of benefit, and likely patient adherence. For a consumer perspective, 22 relatives of the investigators who were also mothers rated each recommendation. RESULTS: Twenty-six organizations identified 160 distinct recommendations; 115 (72%) addressed medication safety, 37 (23%) advised patients about preparation for hospitalization or surgery, and 18 (11%) offered general advice. Organizations most frequently advised patients to make a list of their medications (92% of organizations), to ask questions about their health and treatment (81%), to enlist an advocate (77%), and to learn about possible medication side effects (77%). Investigators assigned high scores to 11 of the 25 most frequently cited recommendations and to 4 of the 25 least common recommendations. There was little association between the frequency with which recommendations were promulgated and investigators' ratings (r = 0.27, p < .001). Investigators' scores correlated with those of the mothers (r = 0.71, p < .001). DISCUSSION: Contrary to expectation, there was little overlap among the 160 recommendations offered by the 26 organizations. Health care organizations offer many patient safety recommendations of limited value. These organizations should offer a concise and coherent set of recommendations on the basis of evidence, magnitude of benefit, and likely adherence.

Medication reconciliation in ambulatory oncology.

BACKGROUND: Few models for medication reconciliation in ambulatory primary or specialty care have been described, perhaps because of the special challenges posed by this environment. METHODS: Dana-Farber Cancer Institute (Boston) created a reconciliation program that was designed as a patient-clinician partnership intervention. Policies that require clinicians to review and update medication lists at regular appointments were augmented. Clinic assistants printed patients' medication lists from the electronic medical record and distributed lists to established patients for review. Patients provided updated lists to their oncology clinicians. Clinicians then entered the information or indicated changes to be entered by a pharmacist. RESULTS: At baseline, 81% of patients' medication lists included at least one error or omission. With medication reconciliation, 90% of incorrect medication lists were updated. In contrast, only 2% of medication lists were corrected among patients who received "usual" care (p < .001). DISCUSSION: From the program's inception in November 2005 through August 2007, patients and staff reconciled 24,148 medication lists by making 53,040 changes to 168,475 listed drugs, a rate of 31 changes per 100 medications. Implementation required broad staff engagement and ongoing attention to operational issues.

Medication safety in the ambulatory chemotherapy setting.

BACKGROUND: Little is known concerning the safety of the outpatient chemotherapy process. In the current study, the authors sought to identify medication error and potential adverse drug event (ADE) rates in the outpatient chemotherapy setting. METHODS: A prospective cohort study of two adult and one pediatric outpatient chemotherapy infusion units at one cancer institute was performed, involving the review of orders for patients receiving medication and/or chemotherapy and chart reviews. The adult infusion units used a computerized order entry writing system, whereas the pediatric infusion unit used handwritten orders. Data were collected between March and December 2000. RESULTS: The authors reviewed 10,112 medication orders (8008 adult unit orders and 2104 pediatric unit orders) from 1606 patients (1380 adults and 226 pediatric patients). The medication error rate was 3% (306 of 10,112 orders). Of these errors, 82% occurring in adults (203 of 249 orders) had the potential for harm and were potential ADEs, compared with 60% of orders occurring in pediatric patients (34 of 57 orders). Among these, approximately one-third were potentially serious. Pharmacists and nurses intercepted 45% of potential ADEs before they reached the patient. Several changes were implemented in the adult and pediatric settings as a result of these findings. CONCLUSIONS: In the current study, the authors found an ambulatory medication error rate of 3%, including 2% of orders with the potential to cause harm. Although these rates are relatively low, there is clearly the potential for serious patient harm. The current study identified strategies for prevention.