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J Med Imaging Radiat Oncol. 2022;66(2):165-309.

Improving patient safety related to radiology and radiation oncology is an ongoing priority. This special issue explores themes related to radiology and radiation oncology, including monitoring and improving quality of care, promoting a culture of safety, and measuring, reporting, and learning from errors.
Weber L, Schulze I, Jaehde U. Res Social Adm Pharm. 2021;Epub Nov 18.
Chemotherapy administration errors can result in serious patient harm. Using failure mode and effects analysis (FMEA), researchers identified potential failures related to the medication process for intravenous chemotherapy. Common failures included incorrect patient information, non-standardized chemotherapy protocols, and problems related to supportive therapy.
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27:1588-1595.
Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.
Bryant J, Carey M, Sanson-Fisher R, et al. J Patient Saf. 2021;17:e387-e392.
When an error or adverse event occurs, patients and families want to be informed. In this study of oncology patients, more than one quarter perceived an adverse event had occurred. While most were informed soon after the event occurred and given an explanation, fewer than half were given information on how to move forward with a complaint if they wished. Regular communication between patients and providers about actual or perceived adverse events may decrease the risk of it happening again.
Cataldo RRV, Manaças LAR, Figueira PHM, et al. J Oncol Pharm Pract. 2021;Epub Mar 30.
Clinical pharmacist involvement has improved medication safety in several clinical areas. Using the therapeutic outcome monitoring (TOM) method, pharmacists in this study identified 43 negative outcomes associated with oral chemotherapy medication and performed 81 pharmaceutical interventions. The TOM method increased patient safety by improving the use of medications.
Dürr P, Schlichtig K, Kelz C, et al. J Clin Oncol. 2021;39:1983-1994.
Patients taking oral anti-cancer drugs may experience severe side effects and medication errors. In this randomized controlled study, patients taking oral chemotherapy drugs were randomized to receive usual care (control) or additional intensive pharmacological/pharmaceutical care (intervention). Patients in the intervention group reported considerably fewer medication errors and side effects and increased treatment satisfaction.
Srinivasamurthy SK, Ashokkumar R, Kodidela S, et al. Eur J Clin Pharmacol. 2021;77:1123-1131.
Computerized prescriber (or physician) order entry (CPOE) systems are widely used in healthcare and studies have shown a reduction in medication errors with CPOE. This study focused on whether CPOE systems improved the incidence of chemotherapy-related medication errors. The study included 11 studies in the review but only 8 studies were in the meta-analysis. The authors found that the use of CPOE was associated with an 81% reduction in chemotherapy-related medication errors, indicating that CPOE is a valuable strategy for this patient population.
Rodrigo Rincón I, Irigoyen Aristorena I, Tirapu León B, et al. BMC Health Serv Res. 2021;21:31.
Engaging patients and families is an essential part of identifying and preventing patient safety events. This study found that an educational intervention providing patients and families with the skills necessary to audit four safe practices (patient identification, hand hygiene, blood or chemotherapy identification, and related side effects) can provide healthcare organizations with valuable quality and safety information.
Mitchell G, Porter S, Manias E. J Adv Nurs. 2021;77:899-909.
Oral chemotherapy regimens are complex and may lead to severe adverse drug events. Through ethnographic research, the authors found that the two most important factors in ensuring optimal management of oral chemotherapy are (1) early recognition and appropriate response to side effects and (2) maintenance of safe and effective medication communication.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 15, 2021. 

Vinca alkaloid misadministration is a persistent problem that results in patient harm and death. This alert raises awareness of label changes that aim to mitigate accidental spinal administration of the high-alert chemotherapy agent by supporting infusion bag administration only. 
Wyatt KD, Freedman EB, Arteaga GM, et al. Cancer Med. 2020;9:8844-8851.
Chemotherapy medications often have complex dosing which can lead to prescribing errors. This article describes the use of simulation-based training to improve pediatric hematology/oncology providers’ ability to identify and mitigate common chemotherapy ordering errors. The authors suggest that simulation-based training can serve as an alternative to systems-based electronic health record (EHR) improvements.
Talcott WJ, Lincoln H, Kelly JR, et al. Pract Radiat Oncol. 2020;10:312-320.
Peer review of radiation oncology patient treatment plans can help prevent harm and reduce errors. In this prospective blinded study, researchers generated treatment plans with simulated errors and randomly inserted these treatment plans into weekly chart rounds to assess the effectiveness of peer review on error detection. Overall detection rate of clinically significant problematic plans was 55%. The authors suggest that error detection could be significantly improved by shortening chart rounds and routine insertion of problematic plans into rounds.
Chun DS, Faso A, Muss HB, et al. J Oncol Pharm Pract. 2020;26:1156-1163.
This study evaluated changes made to the electronic health record (EHR) resulting from pharmacist-led medication reconciliation among patients initiating chemotherapy. Most of the included oncology patients had a medication change identified after medication reconciliation, thereby ensuring physician orders were captured and improving medication safety. Medication changes commonly involving vitamin and herbal supplements (medication additions and modifications) and antimicrobials (medication discontinuations).
Hess E, Palmer SE, Stivers A, et al. J Oncol Pharm Pract. 2020;26:787-793.
This study used one cancer hospital’s incident reporting system to evaluate trends in medication error reporting before and after the implementation of a new electronic health record (EHR) system. After implementation, decreases in reporting were observed for wrong-dose, overdose, wrong duration, and wrong frequency medication errors, likely due to EHR tools such as hard stops on medication doses or prohibiting early or late administration.
Pfeiffer Y, Zimmermann C, Schwappach DLB. J Patient Saf. 2020;Publish Ahead of Print.
This study examined patient safety issues stemming from health information technology (HIT)-related information management hazards. The authors identified eleven thematic groups describing such hazards occurring at a systemic level, such as fragmentation of patient information, “information islands” (e.g., nurses and physicians have separate information sets despite the same HIT system), and inadequate information structures (e.g., no drug interaction warning integrated in the chemotherapy prescribing tool).
Weingart SN, Nelson J, Koethe B, et al. Cancer Med. 2020.
Using a cohort of adults diagnosed with breast, colorectal, lung or prostate cancer, this study examined the relationship between oncology-specific triggers and mortality. It found that patients with at least one trigger had a higher risk of death than patients without a trigger; this association was strongest for nonmetastatic prostate cancer and nonmetastatic colorectal cancer. Triggers most commonly associated with increased odds of mortality were bacteremia, blood transfusion, hypoxemia and nephrology consultation. These findings support the validity of cancer-specific trigger tool but additional research is needed to replicate these findings.
Hemingway MW, Meleis L, Oliver J, et al. AORN J. 2020;111.
Perioperative personnel often care for patients requiring hazardous drugs, and guidelines recommend specific practices to enhance safe delivery. This article describes a protocol developed by one hospital to minimize healthcare workers exposure to the harmful effects of hazardous drugs (e.g., antineoplastic agents). The protocol includes requirements for personal protective equipment for hazardous drugs, the use of spill kits, and proper storage solutions.
Almalki H, Absi A, Alghamdi A, et al. JAMA Netw Open. 2020;3.
Effective communication between patients and physicians is essential to ensuring treatment adherence and improved patient outcomes. This cross-sectional study measured agreement in treatment plan understanding between oncology patients and providers in Saudi Arabia and found that most patients (86.2%) had a suboptimal understanding of their chemotherapy treatment plan. Patients commonly did not understand the planned duration of their treatment or the important toxic effects of chemotherapy.
Marzal-Alfaro MB, Rodriguez-Gonzalez CG, Escudero-Vilaplana V, et al. Health Informatics J. 2020;26:1995-2010.
This study applied failure mode, effect, and criticality analysis (FMECA) methodology to identify the impact of an image-based workflow software on reducing chemotherapy errors. After software implementation, the overall medication error rate decreased significantly, as did all types of errors except wrong medicinal product errors.
Huff C. Clin J Oncol Nurs. 2020;24.
Prior studies have identified medication errors associated with oral chemotherapy. This article discusses the evidence establishing a foundation for standardizing oral chemotherapy safe-handling education for healthcare providers, patients and caregivers. The authors provide an overview of a safe-handling checklist they developed, which consists of 12 educational components that clinicians or homecare nurses can use to facilitate patient and caregiver education.