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Cases & Commentaries
- Web M&M
Jennifer Faig, MD, and Jessica A. Zerillo, MD, MPH; June 2018
Admitted to the oncology service for chemotherapy treatment, a woman with leukemia was noted to be neutropenic on hospital day 6. She had some abdominal discomfort and had not had a bowel movement for 2 days. The overnight physician ordered a suppository without realizing that the patient was neutropenic and immunosuppressed. Unaware that suppositories are contraindicated in neutropenic patients, the nurse administered the suppository. The patient developed a fever soon after receiving the suppository and required transfer to the intensive care unit for hypotension and management of septic shock.
Journal Article > Commentary
Alolayan A, Alkaiyat M, Ali Y, Alshami M, Al-Surimi K, Jazieh AR. BMJ Qual Improv Rep. 2017;6:u211844.w6141.
Complex care regimens and poor team communication can influence the safety of patients with cancer. This project report describes how an organization used a standardized communication tool to augment physician handovers of oncology patients. The authors utilized plan-do-study-act cycles to refine the process. They found that each adjustment addressed challenges to the use of the tool and over time physician compliance with the process increased.