Suffering, Systems, and Safety: Applying the Principles of Systems Safety to Improve the Care of Patients With Cancer

Jacobson, Joseph O.

doi:10.1200/jop.19.00646

Cited by 5 publications

(7 citation statements)

References 16 publications

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“… 9 22–25 Another high-risk area of medicine is cancer care, which often requires exquisite coordination between different specialties including medical oncology, radiation oncology, surgery, pathology and radiology. 26 In addition, there have been major therapeutic advances in cancer care in recent years; new treatments are often complex and carry the potential for significant harm if administered improperly or if poorly coordinated. In medical oncology, whole new therapeutic categories have been introduced including engineered cell therapy, immune checkpoint inhibition and highly targeted agents (often orally administered).…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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“…Potential solutions were stratified using an action hierarchy to rank them on the basis of their potential impact and the resources required for implementation (Fig 3). 28,29 Changes to the e-mail software or the EHR used across the health system to better integrate communication might be beneficial, but such actions would require major structural changes, resources, and political will. Additional high- and intermediate-strength actions considered include changing multidisciplinary evaluations from an opt-in to an opt-out approach for new patients with NSCLC, providing patient navigation, 30 formalizing a handoff process between sites within the health system, and implementing checklists such as those developed by the American College of Physicians to improve multidisciplinary communication.…”

Section: Working Towards Solutionsmentioning

confidence: 99%

Care Fragmentation, Faulty Communication, and Documentation Lapses Derail a Treatment Plan

Roberts

Bailey

Naeem

et al. 2023

JCO Oncology Practice

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This is the second Cancer Morbidity, Mortality, and Improvement Rounds, a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. This case describes the care of a patient who was diagnosed with locally advanced lung cancer during the COVID-19 pandemic; it highlights how gaps in communication and care coordination caused the patient to receive care that did not reflect the consensus of his multidisciplinary team. The discussion highlights the importance of multidisciplinary care, particularly for patients with stage III non–small-cell lung cancer, discusses factors that led to communication gaps, and examines how we should assign accountability across dispersed health care systems. Cancer Morbidity, Mortality, and Improvement Rounds is a series of articles intended to explore the unique safety risks experienced by oncology patients through the lens of quality improvement, systems and human factors engineering, and cognitive psychology. For purposes of clarity, each case focuses on a single theme, although, as is true for all medical incidents, there are almost always multiple, overlapping, contributing factors. The quality improvement paradigm used here, which focuses on root cause analyses and opportunities to improve care delivery systems, was previously outlined in this journal.

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“…However, a panoply of potential risks to patient safety exists including those due to deviations from evidence-based care, to medical errors, to delays, to poorly organized and coordinated care, to unnecessary exposures, and to inequities in care; these are the risks that can result in unnecessary suffering due not to cancer or its treatment, but from system failures. 6 Research efforts to characterize and quantify the risks to patient safety experienced by medical oncology patients have relied largely on retrospective review of medical records, surveys of patients and staff, and review of large databases. The focus has been on characterizing errors in ordering, preparing, administering, and monitoring parenteral and oral chemotherapy.…”

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confidence: 99%

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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Suffering, Systems, and Safety: Applying the Principles of Systems Safety to Improve the Care of Patients With Cancer

Abstract: Author affiliations and support information (if applicable) appear at the end of this article.

Cited by 5 publications

References 16 publications

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

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

Care Fragmentation, Faulty Communication, and Documentation Lapses Derail a Treatment Plan

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

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