By Stephen Sherman, Program Manager, Best Practices
The issues of patient safety and preventing medical errors routinely make headlines, with reports of thousands of preventable deaths and costs in the billions of dollars per year. Far less noticeable, but potentially more important, is the work taking place on a daily basis to develop new systems and processes of safety and use of technology in the effort to reduce preventable adverse events. The 2010 NCCN Patient Safety Summit was held October 14 in Bethesda, Maryland and included a multidisciplinary audience of safety experts, clinicians, and hospital administrators. The Summit examined three primary topics central to maintaining patient safety in the oncology setting: radiation safety, oral chemotherapeutics, and infection control. Panel speakers representing NCCN Member Institutions provided information, centered on those three topics, from their clinical and practical experiences in implementing safety improvements. William T. McGivney, PhD, Chief Executive Officer of NCCN, facilitated the panel discussions following introductory presentations.
In his keynote address, Peter Pronovost, MD, PhD, FCCM, Medical Director for the Center for Innovation in Quality Patient Care at Johns Hopkins Hospitals, spoke about the success of Johns Hopkins in preventing central line-associated bloodstream infections (CLABSI) and how, with funding from the Agency for Healthcare Research and Quality (AHRQ), CLABSI infections were almost entirely eliminated from more than 100 Michigan intensive care units. The cost-effective intervention involved a checklist of evidence-based practices, robust measuring of infections, and improved teamwork among doctors and nurses. The results have endured for nearly five years and, with additional funding from AHRQ, Dr. Pronovost is now working with the American Hospital Association and the Michigan Health and Hospital Association to implement the Michigan program state-by-state across the United States. He also discussed advancing the science of quality improvement via the transformation of cultures and the empowerment of staff members at every level of health care organizations.
Panel Discussion – Radiation Safety: Putting Prevention into Daily Practice
Following the keynote address, Joseph Herman, MD, MSc, Director of the Pancreatic Multidisciplinary Clinic at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, led a presentation on his institution’s efforts to identify points in the treatment process at which potential errors may arise. Hopkins achieved this by constructing a process map listing each person who is in contact with the patient, from consultation, to treatment, to follow-up, creating nodes that pinpoint where an error may occur. Each node was then assigned a score based on Failure Mode and Effect Analysis (FMEA). FMEA ranks any weak points using a calculation that is based on the frequency, detectability, and severity of the occurrence. Dr. Herman also discussed radiation oncology program accreditation and the standardization of processes when implementing new technologies. Panel members for this topic were Steven Brem, MD, Division Chief of the Neuro-Oncology Oncology Department at the H. Lee Moffitt Cancer Center; Jean M. Moran, PhD, Associate Director for Clinical Physics at the University of Michigan; and Brian Napolitano, CMD, Lead Medical Dosimetrist at Massachusetts General Hospital.
Panel Discussion – Strategies to Prevent Oral Chemotherapy Errors
A second panel addressing oral chemotherapy safety commenced with a presentation by Ray Muller, MS, RPh, FASHP, Associate Director of Pharmacy Services at Memorial Sloan-Kettering Cancer Center. Highlighted was the need for robust infrastructure of checks and balances for oral chemotherapy, including order templates, electronic order-entry systems, and clinician double-checks. Safety issues addressed included the lack of checks and balances to avoid medication errors, possible lack of patient adherence, and a shift in the responsibility for managing a potentially complicated oral regimen to patients. Panel members were Sylvia Bartel, RPh, MHP, Vice President of Pharmacy and Clinical Support at Dana-Farber Cancer Institute; Laura Boehnke Michaud, PharmD, BCOP, FASHP, Manager of Clinical Pharmacy Services at The University of Texas MD Anderson Cancer Center; and Steven Newman, MD, Director of Clinical Operations, Section of Hematology/Oncology at the University of Alabama at Birmingham Comprehensive Cancer Center.
Safety and Accountability
Lisa McClane, RN, MSN, Executive Director of Women’s and Children’s Services at The Nebraska Medical Center, and Shirley Johnson, RN, MS, MBA, Chief Nurse and Patient Care Services Officer at City of Hope Comprehensive Cancer Center, presented on their experiences involving medical errors within the context of safety and accountability and “just and fair culture.” Emphasis was placed on encouraging transparency among staff and open discussion of human and medical errors aimed at decreasing adverse patient safety events.
Panel Discussion – Improving the Quality of Cancer Care through the Prevention of Healthcare-associated Infections
A third discussion was introduced by Corey Casper, MD, MPH, Medical Director of Infection Control at the Seattle Cancer Care Alliance (SCCA). Dr. Casper spoke about the success of a multi-pronged infection control program instituted at SCCA in 2007. Although the number of cases of H1N1 in Seattle increased more than 100-fold from the beginning of a pandemic in the spring of 2009 to the end of the year, the total patient population at SCCA experienced no corresponding increase in H1N1 cases. Fred Hutchinson Cancer Research Center (FHCRC), which takes part in the SCCA collaboration, developed an infection control program specifically for ambulatory patients. Although most cancer centers focus their infection control programs on inpatients, Dr. Casper noted that particular emphasis misses an important segment of oncology patients. FHCRC also adheres to universal symptom screening of all patients, visitors, and staff members. Dr. Casper stressed the importance of being open about virus outbreaks, taking proactive measures to prevent them, and publicizing lessons learned. Panel members were Mini Kamboj, MD, Assistant Attending, Infectious Disease Service, Memorial Sloan-Kettering Cancer Center; Stacy Martin, RN, Infection Preventionist Supervisor, H. Lee Moffitt Cancer Center; and Delinda Pendleton, RN, MSN, CPHQ, Director of Quality Management and Infection Control, Fox Chase Cancer Center.