Development of a taxonomy for characterising medical oncology-related patient safety and quality incidents: a novel approach

Jacobson, Joseph O.; Zerillo, Jessica A.; Mulvey, Therese M.; Stuver, Sherri O.; Revette, Anna

doi:10.1136/bmjoq-2022-001828

Cited by 3 publications

(8 citation statements)

References 34 publications

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“…The key component of the project was to assess the ability of the taxonomy to be applied to routinely collected voluntary patient safety reports across 3 distinct sites following standard criteria. 17,18 We randomly selected 309 deidentified incident reports from the same 3 cancer centers initially involved in the validation (Supplemental file A, http://links.lww.com/JPS/A567). Using a structured process, coders were instructed to read each incident carefully, searching for key words or phrases that best explained why the incident reporter placed the entry, and to search the incident and contributing factor code sheets to identify the best fit for each.…”

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

“…In 2020, we developed and validated a medical oncologyspecific incident reporting taxonomy with the hope that the specificity inherent in a specialty-focused system would translate into opportunities to improve the safety of patients receiving systemic treatment for cancer. 17 In the current study, we applied the new taxonomy to characterize several hundred randomly selected incident reports from 3 different cancer centers. The purpose of the analysis was to (1) test its ability to be used in different settings, (2) characterize and quantify patterns of incidents, and (3) identify specific safety risks that could result in future harm for patients receiving anticancer therapy.…”

mentioning

confidence: 99%

“…In 2020, we developed and validated a medical oncology–specific incident reporting taxonomy with the hope that the specificity inherent in a specialty-focused system would translate into opportunities to improve the safety of patients receiving systemic treatment for cancer 17 . In the current study, we applied the new taxonomy to characterize several hundred randomly selected incident reports from 3 different cancer centers.…”

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confidence: 99%

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Uncovering the Risks of Anticancer Therapy Through Incident Report Analysis Using a Newly Developed Medical Oncology Incident Taxonomy

Jacobson,

Zerillo,

Doolin

et al. 2023

J Patient Saf

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Background Incident reporting systems were developed to identify possible and actual harm in healthcare facilities. They have the potential to capture important safety trends and to enable improvements that can mitigate the risk of future patient harm and suffering. We recently developed and validated a taxonomy specific for medical oncology designed to enhance the identification, tracking, and trending of incidents that may lead to patient harm. The current project was designed to test the ability of such a taxonomy to be applied across different organizations delivering medical oncology care and to identify specific risks that could result in future harm. Methods We analyzed 309 randomly selected medical oncology–related incident reports from 3 different cancer centers that had been posted between January 2019 and December 2020. Each report was assigned up to 2 incident categories. We used a 2-step process to reconcile reviewer discrepancies. In a secondary analysis, each of the incidents was reviewed and recoded to identify events which may result in major or catastrophic harm. Results Three hundred four incidents met criteria for inclusion. Three hundred incidents (98.7%) were successfully coded. Sixty-seven percent of incidents were encompassed by the following 4 of 21 categories: prescriber ordering (22%), nursing care (15%), pharmacy (14%), and relational/communication issues (15%). Of 297 evaluable incidents, 47% did not reach the patient, 44.7% reached the patient without harm, 7.7% caused minor injury, and 0.7% caused severe injury or death. Submission rates by physicians varied between the 3 sites accounting for 1.7%, 10.7%, and 16.1% of reports. Secondary analysis identified 9 distinct scenarios that may result in major or catastrophic patient harm. Conclusions A medical oncology–specific incident reporting taxonomy has the potential to increase our understanding of inherent risks and may lead to process improvements that improve patient safety.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Uncovering the Risks of Anticancer Therapy Through Incident Report Analysis Using a Newly Developed Medical Oncology Incident Taxonomy

Jacobson,

Zerillo,

Doolin

et al. 2023

J Patient Saf

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“…15 We designed our study to (1) quantitatively examine the characteristics associated with malpractice claims against medical oncologists (MO) as compared to other internal medicine subspecialties (OIMS), and (2) thematically explore safety signals via coding a subset of claims using a validated medical oncology safety incident taxonomy as an organizing framework. 16,17 Our aim was to assess the framework on a set of malpractice claims that had been analyzed against a generic set of contributing factors to provide a more nuanced understanding of oncology care issues. Finally, during the qualitative categorization process, we recognized an opportunity to identify claims associated with systems failures amenable to potential redesign solutions rather than individual provider remediation and then thematically categorized claims in this way.…”

Section: Introductionmentioning

confidence: 99%

An analysis of medical malpractice claims against medical oncologists from a national database: Implications for safer practice

Doolin,

Schaffer,

Tishler

et al. 2023

J of Healthc Risk Manag

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Malpractice claims data include valuable information about patient safety. We used mixed methods to analyze claims against medical oncologists (MO) from 2008 to 2019 using a national database. MO claims were compared to a group of other internal medicine subspecialties (OIMS). Logistic regression was used to examine correlates of closing with an indemnity payment. A subset of claims against MO were thematically analyzed using a validated safety incident taxonomy as a framework. 456 claims against MO were compared with 5771 claims against OIMS. MO claims closed with indemnity payments 29.8% of the time versus OIMS 30.3% (p = 0.87). Median MO and OIMS indemnity payments were similar ($190,591 vs. $233,432; p = 0.20). Correlates of MO claims closing with payment included patient assessment, communication among providers, and safety and security as contributing factors. Thematic analysis identified provider cognitive error, adverse drug events and relational problems as the most common safety incidents. MO malpractice claims have similar outcomes to OIMS. We demonstrate the proof‐of‐concept of applying a safety incident taxonomy to medical malpractice. Finding ways to reduce patient exposure to provider cognitive errors, adverse drug reactions, and communication breakdowns should be strategic priorities for safer cancer care.

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Taxonomy development methods regarding patient safety in health sciences – A systematic review

Syyrilä,

Koskiniemi,

Manias

et al. 2024

International Journal of Medical Informatics

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Development of a taxonomy for characterising medical oncology-related patient safety and quality incidents: a novel approach

Cited by 3 publications

References 34 publications

Uncovering the Risks of Anticancer Therapy Through Incident Report Analysis Using a Newly Developed Medical Oncology Incident Taxonomy

Uncovering the Risks of Anticancer Therapy Through Incident Report Analysis Using a Newly Developed Medical Oncology Incident Taxonomy

An analysis of medical malpractice claims against medical oncologists from a national database: Implications for safer practice

Taxonomy development methods regarding patient safety in health sciences – A systematic review

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