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Joseph O. Jacobson, MD, MSc, and Saul N. Weingart, MD, PhD; May 2013
A cancer patient expecting to be discharged from the hospital after his usual 3-day regimen was surprised to hear that he has 2 more days of chemotherapy. He asked to speak with the oncology team, who discovered that although the right medications were ordered, the wrong duration and dosage were selected on the order set.
Journal Article > Study
Weingart SN, Price J, Duncombe D, et al. Jt Comm J Qual Patient Saf. 2007;33:83-94.
This study assessed the ability of patients to detect medical errors through an innovative mechanism of using patient safety liaisons (trained patient and family volunteers) to conduct interviews of patients at an outpatient chemotherapy center. Patients' responses to open-ended questions were reviewed by physicians, who classified reported adverse events as adverse events, near misses, or problems with service quality (eg, delays or poor communication). Patients demonstrated good understanding of safe practices in outpatient chemotherapy, and nearly one-fourth of the patients felt they had experienced unsafe care. However, only 1% of the reported events were classified as true medical errors with potential for harm. The vast majority of events related to service quality rather than quality of care. Prior research also assessed the relationship between patient perceptions of care quality and service quality.
Journal Article > Study
Weingart SN, Toro J, Spencer J, et al. Cancer. 2010;116:2455-2464.
Widely publicized errors associated with chemotherapy catalyzed extensive efforts to improve safety for patients receiving traditional intravenous chemotherapy. However, an increasing number of cancer patients are prescribed oral chemotherapy, and a prior study found that most cancer centers lack formal safety protocols for these medications. This AHRQ-funded analysis used multiple data sources to identify and characterize oral chemotherapy medication errors, and found that most errors resulted from dispensing incorrect dosages or medications—similar to prior studies of outpatient chemotherapy errors. The authors conclude that standardized safety practices for oral chemotherapy are urgently needed.