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Multidisciplinary Systems Approach to Chemotherapy Safety: Rebuilding Processes and Holding the Gains

From the Department of Pediatrics and School of Nursing, University of Pennsylvania, and Division of Oncology and Departments of Pharmacy and Nursing, The Children’s Hospital of Philadelphia, Philadelphia, PA.

Address reprint requests to Richard B. Womer, MD, Division of Oncology, The Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104; email: rwomer{at}mail.med.upenn.edu

PURPOSE: The problem of medication safety came to public attention largely through a chemotherapy error, and the high toxicity and low therapeutic index of anticancer medications make safety in their prescription and administration critical. We have undertaken a thorough revision of our systems for inpatient chemotherapy.

METHODS: We participated in a multi-institutional collaborative effort of the Institute for Healthcare Improvement, and used their rapid cycle change method. Particularly powerful systems change concepts were driving out fear, "trapping" errors and learning from them, focusing on outcome rather than on input, simplifying and standardizing, using constraints and "forcing functions," reducing handoffs, and paying attention to human factors.

RESULTS: Applying these concepts to our chemotherapy delivery system, we have achieved an 84% decrease in the number of chemotherapy errors that actually reach patients per 1,000 chemotherapy doses, and have sustained that improvement for 5 years.

CONCLUSION: Factors contributing to our success include the rapid cycle change method, strong support from hospital administration, grassroots participation, and a tradition of interdisciplinary cooperation. Computerized direct physician order entry and cooperative group participation have had mixed effects. Continued efforts at improvement have been key to holding our gains. Although specific problems and changes may not be relevant to other organizations, the concepts and methods we used are generally applicable.

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