Electronic prescribing systems with decision support may improve patient safety in ambulatory care by offering drug allergy and drug interaction alerts. However, preliminary studies show that clinicians override most of these alerts.
Methods
We performed a retrospective analysis of 233 537 medication safety alerts generated by 2872 clinicians in Massachusetts, New Jersey, and Pennsylvania who used a common electronic prescribing system from January 1, 2006, through September 30, 2006. We used multivariate techniques to examine factors associated with alert acceptance.
Results
A total of 6.6% of electronic prescription attempts generated alerts. Clinicians accepted 9.2% of drug interaction alerts and 23.0% of allergy alerts. High-severity interactions accounted for most alerts (61.6%); clinicians accepted high-severity alerts slightly more often than moderate- or low-severity interaction alerts (10.4%, 7.3%, and 7.1%, respectively;P < .001). Clinicians accepted 2.2% to 43.1% of high-severity interaction alerts, depending on the classes of interacting medications. In multivariable analyses, we found no difference in alert acceptance among clinicians of different specialties (P = .16). Clinicians were less likely to accept a drug interaction alert if the patient had previously received the alerted medication (odds ratio, 0.03; 95% confidence interval, 0.03-0.03).
Conclusion
Clinicians override most medication alerts, suggesting that current medication safety alerts may be inadequate to protect patient safety.
Context. Pain is common among patients with advanced cancer despite the dissemination of clinical pain care guidelines. Objectives. We sought to assess the quality of pain care among patients with advanced disease. Methods. We reviewed the records of 85 adult ambulatory patients with advanced breast, lung, and gastrointestinal cancer treated in 2004e2006. Patients’ screening pain intensity scores were at least 7 of 10. Nurse reviewers completed medical record reviews of care rendered at the index visit and over the subsequent 30 days based on the 2004 National Comprehensive Cancer Network pain guideline. An expert panel then rated the quality of the evaluation, treatment, and overall pain care. We used a multivariable modeltoanalyze guidelinecomplianceand resolution ofseverepain. Results. Among advanced cancer patients with severe pain, clinicians adjusted pain medications only half the time and made few timely referrals for pain-related consultations. By 30 days after the index visit, 34% of patients continued to report severe pain. The expert panel judged the overall quality of pain care as ‘‘fair’’ or ‘‘poor’’ in about two-thirds of cases because more timely and effective intervention could have reduced the severity and duration of pain. Resolution of severe pain was associated with adjustment of pain medications at the index visit (adjusted odds ratio 3.8, 95% CI 1.3e10.6). Conclusion. There is room for improvement in the pain care of patients with advanced cancer. Additional research is needed to understand the reasons for poor performance. J Pain Symptom Manage 2012;43:1072e1081. 2012 U.S.
Oncology clinicians readily accepted features designed to enhance oral chemotherapy safety. Additional enhancements are needed to facilitate prescriptions with complex dosing regimens.
Although many patients prefer orally administered cancer therapy (including oral chemotherapy) because of its convenience, the shift from hospital to home-based administration creates concerns. This article explores the perceptions and experiences of oral chemotherapy users and their caregivers to assess vulnerabilities and improvement opportunities at each stage of the medication process: choosing oral chemotherapy, prescribing, dispensing, administering, and monitoring. The authors recruited 15 current and former oral chemotherapy users, as well as caregivers who administered the medications to children, to participate in one of two focus group sessions at a comprehensive cancer center. Participants largely were satisfied with oral cancer therapy but raised concerns regarding their lack of preparedness for side effects and their unfamiliarity with the possible techniques to mitigate drug toxicity. Participants also described difficulties obtaining medications through retail pharmacies. Parents of pediatric patients with cancer indicated concerns regarding their children's emotional health and correct medication administration. Participants believed that the initial prescribing encounter should have included more education, and they also wanted more frequent follow-up by healthcare practitioners. As oral cancer therapy is used more widely, oncology healthcare providers will need to create robust mechanisms to support their safe use.
51 Background: Delayed chemotherapy is associated with adverse clinical outcomes for breast cancer patients. Few studies have examined the processes of care within administrative staff and providers’ control that might affect the timeliness of breast cancer care. Coordinating transitions of care from surgical to medical oncology to eliminate variation is essential in ensuring timely chemotherapy for patients after surgery. This study evaluated the time of transition from surgery to medical oncology when administrative change of practice was implemented. Methods: We studied 192 consecutive breast cancer patients who received adjuvant chemotherapy. The interval between last definitive surgery and initiation of chemotherapy was calculated by integrating billing and scheduling data. Using process improvement methods a multidisciplinary team identified the opportunity to reduce delays in care coordination by scheduling the surgery, surgical post-op appointment, and medical oncology follow-up appointments simultaneously. Furthermore, responsibility for scheduling the medical oncology follow-up appointment was shifted and standardized from medical to surgical oncology administrative staff. Criteria for acceptable timeliness of appointments and escalation pathways for when provider availability was limited were established. The intervention targeted patients whose initial consultation with a breast surgeon and medical oncologist occurred on the same day, the standard practice at our institution. Results: Implementation of the interventions decreased the time from surgery to chemotherapy by six days. The standard deviation also declined, suggesting that the intervention reduced process variability. Conclusions: Standardizing administrative practices between breast surgery and medical oncology has led to a significant decrease in the time from last definitive surgery to initiation of chemotherapy and in the variability of that delay. [Table: see text]
To develop a patient safety culture instrument for use in Chinese hospitals, we assessed the appropriateness of existing safety culture questionnaires used in the USA and Japan for Chinese respondents and identified new items and domains suitable to Chinese hospitals. Focus group study. Twenty-four physicians, nurses and other health-care workers from 11 hospitals in three Chinese cities. Three focus groups were conducted in 2010 to elicit information from hospital workers about their perceptions of the appropriateness and importance of each of 97 questionnaire items, derived from a literature review and an expert panel, characterizing hospital safety culture. Participants understood the concepts of patient safety and safety culture and identified features associated with safe care. They judged that numerous questions from existing surveys were inappropriate, including 39 items that were dropped because they were judged unimportant, semantically redundant, confusing, ambiguous or inapplicable in Chinese settings. Participants endorsed eight new items and three additional dimensions addressing staff training, mentoring of new hires, compliance with rules and procedures, equipment availability and leadership walk-rounds they judged appropriate to assessing safety culture in Chinese hospitals. This process resulted in a 66-item instrument for testing in cognitive interviews, the next stage of survey development. Focus group participants provided important insights into the refinement of existing items and the construction of new items for measuring patient safety culture in Chinese hospitals. This is a necessary first step in producing a culturally appropriate instrument applicable to specific local contexts.
