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- Title
IMPLEMENTATION OF AN INTERDISCIPLINARY TEAM TO IMPROVE MEDICATION SAFETY.
- Authors
Mullaly, Katie; Scagliola, Joan; DelCorral, Thomas; Sziklai, Vera; Speyer, James; Duthie, Elizabeth; Kirchen, Kevin
- Abstract
Medication delivery in an ambulatory cancer center is a complex process that includes prescribing, processing, dispensing, administering and side effect monitoring. A review of errors in the infusion area of the Clinical Cancer Center revealed that volume was low compared to the number of drugs administered daily; however each potential error carried a high patient safety risk. An Interdisciplinary Medication Safety Committee was organized consistent with the ONS position statement on medication safety. Membership included nursing, pharmacy, patient safety officer, medical director, and administration. The goal of the committee was to develop and implement a system that would improve communication and to facilitate the detection and correction of errors before they reach a patient and cause harm. A root cause analysis of near miss/medication errors was conducted which revealed multiple system issues. An action plan was developed and implemented that included the following: an anonymous medication safety hotline, pharmacy system redesign, mandatory treatment plan, specific chemotherapy agents mixed prior to patient appointment, centralized nursing model changed to primary nursing, electronic ordering system, nursing/physician teams developed to improve communication. Weekly meetings were organized to identify and address issues related to the ongoing changes. Frequent communication with all stakeholders was crucial to the success of this initiative. Achieved outcomes included appropriate utilization of hotline, decreased number of near miss errors, and implementation of electronic orders. The electronic orders resulted in the elimination of incomplete and illegible orders, increased accessibility to order entry/review for clinicians, decreased patient wait time and improved staff satisfaction. Consistent with the ONS position statement on medication safety, the medication safety committee's aim of preventing future errors and potential patient harm was realized. Nursing, physician and pharmacy staff report improved communication, staff satisfaction, ease of work flow and increased productivity. Patients are pleased with the decreased wait time.
- Subjects
HOSPITAL drug distribution systems; CANCER hospitals; COMMITTEES; INTERDISCIPLINARY research; ONCOLOGY nursing; MEDICAL communication; HOSPITAL purchasing; LABOR productivity
- Publication
Oncology Nursing Forum, 2007, Vol 34, Issue 2, p560
- ISSN
0190-535X
- Publication type
Article