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- Communication Improvement
- Culture of Safety 1
- Education and Training 3
- Error Reporting and Analysis 2
- Human Factors Engineering 3
- Quality Improvement Strategies 4
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External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Toft B. London, England: Department of Health; 2001.
This UK Department of Health report details a series of errors that led to the death of a young man due to wrong route administration of the chemotherapy drug vincristine. The fatality occurred as a result of a socio-technical systems failure at the hospital where he received the injection. The report makes 48 recommendations to help minimize the likelihood of this mistake.
World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2008.
Through a discussion of a vincristine administration error, this booklet and video illustrate how system weaknesses can contribute to failure.
Feinmann J. BMJ. 2009;338:b420.
This news article highlights a National Patient Safety Agency campaign to achieve safer care through five interventions.
Journal Article > Study
Lipczak H, Knudsen JL, Nissen A. BMJ Qual Saf. 2011;20:1052-1056.
A comprehensive view of patient safety hazards requires identifying safety issues through multiple data sources. This Danish study analyzed safety problems in oncology care through voluntary error reports, retrospective chart review using the Global Trigger Tool, and patient reports. While each data source revealed unique hazards, common problems in this patient population included treatment-related harm (from chemotherapy and other procedures), health care–associated infections, and problems related to communication between providers. An AHRQ WebM&M commentary discusses a preventable complication in a patient receiving outpatient chemotherapy.
Journal Article > Study
Prioritizing medication safety in care of people with cancer: clinicians' views on main problems and solutions.
Car LT, Papachristou N, Urch C, et al. J Glob Health. 2017;7:011001.
Patients with cancer are at increased risk of medication errors in both the inpatient and outpatient settings. In this study, investigators solicited input from cancer care clinicians regarding their perception of causes and potential solutions for medication errors. Clinicians identified limited health literacy and inadequate information sharing among clinicians as barriers to providing safe care and they suggested increased patient engagement as one potential approach to improving safety.