Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 1
Education and Training
- Students 1
- Error Reporting and Analysis
- Logistical Approaches 1
- Quality Improvement Strategies
- Teamwork 1
Search results for "Specific to High-Risk Drugs"
Journal Article > Commentary
Lennes IT, Bohlen N, Park ER, Mort E, Burke D, Ryan DP. J Oncol Pract. 2016;12:e495-e501.
Chemotherapy is a complicated process, and it is vulnerable to error due to factors that can affect the various steps involved. This commentary describes how one multidisciplinary cancer center designed and applied a taxonomy to report and monitor chemotherapy errors. The authors summarize the results of the work and provide suggestions for organizations that seek to develop similar tracking and analysis methods.
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.
Cases & Commentaries
- Spotlight Case
- Web M&M
F. Daniel Duffy, MD; Christine K. Cassel, MD; October 2007
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.