Reducing Preventable Harm: Quality Improvement Strategies to Reduce Chemotherapy/Biotherapy Medication Administration Errors (203-2)

11:15 – 11:45 am Wednesday, September 2

Medication administration errors (MAE) are among the most common adverse events causing patients during treatment. These events are nearly always preventable. Although any MAE is problematic, patients treated with chemotherapy and biotherapy agents are at risk for significant harm due to the inherent hazards of the medications and the complexity of treatment protocols.

Nurses caring for pediatric patients with hematologic or oncologic disorders or undergoing bone marrow transplantation (HOB) often describe medication administration as a significant stressor due to the complicated treatment regimens and high risk for patient harm if mistakes are made. As new treatment modalities and medications become available to treat HOB patients, medication administration becomes even more challenging for nurses. Decreasing variability in administration practices is key to avoiding MAE related events. Quality improvement (QI) strategies have been proven effective at identifying and reducing variability in practice. This interactive educational session will provide guidance on developing a QI project that addresses potential errors in all stages of medication administration, utilizing the Institute for Healthcare Improvement (IHI) methodology. Attendees will participate in the development of an aim statement and key driver diagram and identify potential interventions to address drivers. Review of current best practices, including the importance of multidisciplinary teams, will formulate the drivers. Highlighted strategies will include how to develop a culture of high reliability, detecting and reporting errors, and addressing common process-related errors that contribute to MAE. A review of one institution’s QI project aimed to reduced MAE in HOB patients will demonstrate the effectiveness of selected interventions. Through the utilization of proven QI strategies, this institution has eliminated nearly all harm related to MAE in patients receiving chemotherapy and biotherapy agents.

CNE Hours: