bluuebunny/crossref_metadata_2025_split huggingface dataset:
Root cause analysis: A framework using principles of high reliability.
Authors: Denny, DBA Diane , Shinners Caitlyn , Hepler Marjorie 
Published: October 2019

233 Background: Medical errors are the 4th leading cause of death in the US. Oncology providers are not immune to errors. A network of hospitals and outpatient centers recognized an opportunity to enhance and standardize our approach to root cause analyses (RCAs). As leaders, we have an imperative to prevent issues that can result in a safety event; yet we have an even greater moral obligation to correct causes once an event occurs to prevent it from happening again. Methods: A framework was established to prevent recurrence through a focus upon root solutions. Recognizing that human error is not the cause of the failure but a symptom, the goal is to understand why it made sense for individuals to do what they did by reconstructing the world in which they found themselves at the time of the event. The includes: 1) training staff on high reliability; 2) assigning an executive to remove barriers; 3) creating a charter; 4) conducting 1:1 interviews; 5) deploying tools (such as sequence of event diagramming, validation and verification of raw data, human error type classification; individual/system failure and event/causal factor charting); 6) transporting findings; and 7) action planning with controls. A 3-meeting model was embraced. Results: As of April 2019, 9 events have been investigated. Event types include: infusion hours/splitting orders, incorrect lab order, retained object, wrong patient medication administration, patient brachytherapy underdosing, wrong site delayed treatment, rapid response call delay, and delay in care for extravasation. The 12-month rolling average serious safety event rate per 10,000 patient days decreased from 1.93 to 1.33 since implementation. With 6 months experience under the enhanced framework, plans also exist to monitor events from similar root causes as a success measure. Summaries allowing this level of analyses include event description, immediate actions, proximate versus root causes, and corrective actions. Conclusions: The capacity to learn from experience is essential to patient safety. Adherence to the framework ensures movement beyond proximate to root causes. It is a means to spread knowledge using proven tools based upon principles of high reliability.
Transforming a cancer center into a high reliability organization.
Authors: Pavlick Anna C. , Duffy Fray Kathleen C. , Rabinovich Annette C. , Wertheimer Benjamin C. 
Published: October 2019

234 Background: The goals of a high reliability organization (HRO) are to eliminate preventable harm and streamline processes to maximize efficiency. The NYU Langone Medical Center embarked upon transforming the entire organization into an HRO. Educating the staff of the NYU Perlmutter Clinical Cancer Center (NYUPCCC) about the principles of HRO and a stepwise rollout began in March 2018. Methods: All cancer center employees were provided with an anonymous survey designed to assess culture, teamwork and burnout. Response rate to the survey was 83%. The survey evaluated 8 areas: improvement readiness, local leadership, teamwork climate, safety climate, decision making, burnout climate, personal burnout and emotional recovery. Three areas of opportunity were identified: teamwork and communication, discussing and correcting errors and participation in decision-making. Implementation and onboarding of the NYUPCCC occurred in 3 phases due to the physical layout of the center. Infusion floors were paired with physician floors that utilized them. Three “aims” for each floor were proposed with one aim being an overlapping aim that would require collaboration between the treatment and physician floors. Weekly “huddles” at a white board occur at a defined time and is led by a different staff member each week. This 15-minute gathering of all floor staff allows for an open exchange of ideas, verbalization of new areas of improvement and staff acknowledgement who provided a service above and beyond expectations. Initiatives and results will be presented. Results: This initiative had a positive impact on culture, improved staff-wide communication, improved physician efficacy and decreased patient wait times through the utilization of staff generated ideas and processes. It identified the need for better physician engagement. It also identified a data collection challenge so that information could be gathered in real time and metrics analyzed promptly. Conclusions: Transforming the NYUPCCC into an HRO identified opportunities for staff to encourage a culture of acceptance, foster teamwork, enhance overall cancer center communication and streamline processes to maximize patient safety and overall system efficiency.
Association of electronic medical record (EMR) QTc alerts with higher mortality within 10 days for patients with blood, lung, GI, and soft tissue cancer.
Authors: Bleiberg Benjamin Aaron , Xie Donglu , Lightfoot Tammy , Reisch Joan , Khan Saad A. 
Published: October 2019

235 Background: Patients with cancer receive many prescriptions associated with QTc interval prolongation. Prognostic implications of drug-induced QTc interactions are unknown. EMR's regularly generate QTc-alerts but their significance or impact is not known. Methods: Using the UTSW tumor registry we identified 14,731 adult cancer patients from 2005-2018 for whom the EMR had generated 16,797 unique alerts for potential QTc drug interactions. We collected patient cancer details, demographics and specific drugs prescribed. After a QTc alert, timing of patient death within a < 365 day period was recorded and analyzed. Prior studies have defined death within 10 days as acute mortality that may be related to QTc prolongation-associated factors. We compared actual deaths that occurred ≤10 days from a QTc alert to expected deaths based on the null hypothesis that deaths ≤10 days were evenly distributed by cancer primary site and would be proportionate to the number of patients in each group; data were analyzed by chi-squared goodness of fit testing. Results: The number of ACTUAL deaths ≤10 days compared to those EXPECTED by the null model varied significantly by cancer site (Table). No mortality differences were noted based on patient demographics, age at first alert, ethnicity, or race. Conclusions: There is a significant association between EMR QTc alerts and higher than expected acute mortality for some cancers, but not universally. In lung, breast, and GI cancer patients who died <365 days of a QTc alert, > 15% died within 10 days of a QTc alert. EMR generated QTc alerts may identify cancer patients who are at imminent risk of death in some cancers but may represent distractions in other types of cancers. [Table: see text]
Developing clinical indicators to effectively monitor a large network of radiation oncology practices.
Authors: Frey Seth D. , Hoffman Karen E. , Jhingran Anuja , McAleer Mary Frances , Minsky Bruce D. , Kirsner Steve , Arora Gurpreet , Zaebst Denise , Robinson Ivy , Roberts Terence , Patel Ashish Bharat , Olson Michael Ray , Gabel Molly , Bolukbasi Yasemin , Llorente Manolo , de Carvalho Icaro Thiago , Ghafar Robert , Koong Albert , Herman Joseph M. , Kuban Deborah A. 
Published: October 2019

236 Background: The MD Anderson Cancer Network includes 29 distinct Radiation Oncology facilities spread across metropolitan Houston area locations, national partnerships, and international affiliates. Standard performance indicators (PIs) were developed to monitor the quality and safety of radiation treatment at these facilities spread across the globe. Methods: Stakeholders from Radiation Oncology nursing, dosimetry, physics, radiation therapy, and clinical operations identified PIs that measure safe, efficient, and effective radiation oncology care. PIs are collected monthly from each facility and are reported in a scorecard that includes performance goals. The appropriateness and effectiveness of the PIs are reviewed annually to determine if PIs need to be added, removed, or revised. Results: As the network expanded, scorecard use expanded from 11 facilities in 2013 to 29 facilities in 2019. Select PIs are summarized in the table. Scorecard composition has evolved over time. PIs such as completion of simulation orders and treatment planning directives were removed once consistently reaching 100% after improved monitoring, process improvements, and implementation of hard stops. The scorecard has been especially useful when onboarding new facilities, as evidenced by PIs increasingly meeting performance thresholds in the first year after joining the network. For example, one facility increased PI compliance from 61% to 100% the first year after joining the network. Conclusions: It is feasible to develop and implement a performance indicator scorecard across a large radiation oncology network. The scorecard permits timely assessment of quality indicators, provides oversight, and is effective in stabilizing operations at newly on-boarded radiation oncology practices. [Table: see text]
Developing a cancer-specific trigger tool to identify adverse events using administrative data.
Authors: Weingart Saul N. , Koethe Benjamin , Nelson Jason , Yaghi Omar , Kent David M. , Hassett Michael J. , Lipitz-Snyderman Allison 
Published: October 2019

238 Background: “Trigger tools” identify complications of care and potential patient safety hazards. However, attempts to create triggers that flag treatment-related complications in oncology have been largely unsuccessful. To address this problem, the authors built a set of claims-based oncology-specific triggers based on a promising pilot study conducted at Memorial Sloan-Kettering Cancer Center. Methods: We selected subjects from the OptumLabs data warehouse, a repository of > 160 million de-identified patients drawn from commercial claims. The cohort included patients with breast, colorectal, lung, and prostate cancer undergoing an initial course of cancer-directed therapy from 2008-14. Using ICD and CPT codes, we defined 16 oncology-specific triggers drawn from the pilot study, all with PPVs ≥50%. Triggers included events such as neutropenic fever, abnormal serum potassium or bicarbonate, and initiation of therapeutic anticoagulation. To distinguish treatment-related complications from other comorbidities, we required a logical and temporal relationship between a treatment and the associated trigger. We tabulated the prevalence of cancer triggers by cancer type and metastatic status during a one-year follow up period and created multivariate logistic regression models to examine the association of triggered cases with one-year mortality. Results: The cohort comprised 369,354 unique subjects including 29% with metastatic disease. The prevalence of triggered events was greatest among non-metastatic patients with lung (33%) and colorectal (21%) cancers, and among those with metastatic disease. The most common triggers included abnormal chemistry tests, blood transfusions, hypoxemia, and chest CT following radiation therapy. The mortality rate was substantially higher among patients with at least one trigger compared to patients with none. Experiencing at least one cancer-specific trigger increased the one-year risk of death by 1.69 (95% CI 1.28-2.24). Conclusions: Oncology-specific triggers provide researchers a promising method for studying patient safety in cancer care.
Guideline adherence and the strategy of chemotherapy dose reduction in metastatic colorectal cancer: A multicenter oncology practice experience.
Authors: Orji Chinelo C. , Brown Carolyn M. , Hoverman J. Russell , Richards Kristin M. 
Published: October 2019

24 Background: Current American Society of Clinical Oncology (ASCO) guidelines recommend prophylactic use of colony stimulating factors (CSF) for prevention of febrile neutropenia among cancer patients. ASCO also recommends chemotherapy dose reduction as a viable alternative to CSF administration, which may result in cost savings to patients and payers, but adherence to these guidelines has been less than ideal. The objectives of this study were i.) to determine the prevalence and prescribing patterns of CSF and dose reduction in metastatic colorectal cancer patients and ii.) to evaluate the impact of a program initiative on CSF prescribing patterns and on compliance to ASCO guidelines. Methods: In this retrospective study, we utilized data from the electronic health records of metastatic colorectal cancer patients who received care at a multi-center oncology practice network during two time periods: July 2013 to December 2014 and July to December 2017. In 2016, a site-wide program initiative that involved educational materials, appropriate non-use recommendations and prior authorization was introduced in the oncology practice network with an aim of reducing CSF overutilization. Descriptive statistics and chi squared tests were employed to explore CSF utilization across patient age, gender, disease, year of diagnosis, febrile neutropenia risk, line of therapy and duration of treatment. Results: There were 3426 chemotherapy regimens corresponding to 2968 patients. There was a total of 3095 CSF administrations and the CSF administered was pegfilgrastim. There were 343 (10%) CSF users. Among subjects who had data on dose reduction (N = 508), 58.7% received dose reduction. CSF use was significantly lower in the post-period, compared to the pre-period (p < 0.0001). Compliance to guidelines was significantly higher in the post-period, compared to the pre-period (p < 0.0001). Conclusions: Our results demonstrate that program initiatives have the potential to positively impact CSF prescription patterns. These findings could help prescribers adopt a cost-effective approach for this population, leading to enhanced clinical practice and value-based care.
A quality improvement initiative for reducing morning hypoglycemia in children undergoing treatment for acute lymphoblastic leukemia.
Authors: Mohamed Ashraf Mahmoud , Bolen Christine Marie , Morgan Jennifer , Rice Patricia , Speas Meredith , Russo Carolyn 
Published: October 2019

240 Background: Hypoglycemia has been observed in children receiving Acute Lymphoblastic Leukemia (ALL) therapy. It affects patients’ outcome. The current quality initiative was piloted at two of the St Jude affiliate clinics. Each month about 10% of children with ALL develop hypoglycemia in those two clinics. Methods: Data was collected for the eight months prior to intervention. Root Cause Analysis (RCA) using fish bone diagram, and Pareto chart to find out the most likely causes of hypoglycemia. Prolonged hours of fasting for procedures, giving 6MP at night on empty stomach, seem to further prolong hours of fasting, and lack of awareness of the new 6MP administration guidelines were the top likely causes. Interventions based on RCA: Developed Hypoglycemia educational brochure addressing causes and prevention of hypoglycemia for care givers followed by knowledge assessment tool, in addition two educational sessions for staff. Plan, Do, Study, Act (PDSA) was used to guide implementation. 4 PDSA cycles were done. Results: Combined monthly average number of ALL patients seen in both centers was 43 (range 38-51) patients with monthly average of 94 (range 71-141) blood glucose samples drawn from them. Process Measure 1: % care givers received hypoglycemia education after 1st cycle was 16.3% which increased to 88% after PDSA cycle # 4. Process Measure 2: % of caregivers scored above 75% in the knowledge of morning hypoglycemia after education were 78%. Outcome Measure: At the end of intervention the average monthly patients with hypoglycemia decreased from 9.4% to 7.8% representing 17% reduction. Hypoglycemic episodes dropped from 6% to 4.2%, showing 30% reduction in hypoglycemic episodes. More reduction in hypoglycemic episodes was observed in clinic 1 (68%) compared to 22% reduction in clinic 2. Conclusions: Using quality improvement methodology in implementing hypoglycemia education led to drop in hypoglycemia episodes among children on ALL therapy. Despite using similar approach, yet one of the two clinics showed higher improvement compared to the other. This may reflect the possible impact of local institutional factors on implementation.
The impact of depression in cancer patients on healthcare utilization.
Authors: Ye Star , Gilbert Aidan , Huang Chao-Hui , Rocque Gabrielle Betty 
Published: October 2019

243 Background: The Oncology Care Model (OCM) has set several initiatives to improve payment and care delivery in the Medicare patient population, including screening for depression in cancer patients. We evaluated the prevalence of depression in OCM patients and the relationship between depression and healthcare utilization. Methods: This cross-sectional study used patient-reported outcome (PRO) surveys administered in the outpatient setting as part of OCM at the University of Alabama at Birmingham (UAB). Depression scores and Eastern Cooperative Oncology Group performance status were obtained from PRO surveys. Moderate to severe depression was defined as a score ≥10 on the Patient Health Questionnaire 2/9 (PHQ-2/9). Sex, marital status, phase of care, race, disease aggressiveness (stage, progression, cancer type), number of emergency department (ED) visits and inpatient admissions within a 3-month period from survey completion were abstracted from the electronic health record. The relationship between depression and hospital visits was assessed using rate ratios and 95% confidence limits from Poisson regression models adjusting for clinical and demographic characteristics. Results: Of 856 patients surveyed, 68% of patients were female, and 27% of patients were non-Caucasian. Notably, almost 14% of patients had moderate to severe depression (PHQ-2/9≥10). The cancer-specific prevalence of at least moderate depression was 2% in breast, 1% in gastrointestinal, 2% in genitourinary, 5% in gynecologic, and 2% in hematologic cancers. In adjusted models, the inpatient admission and ED visit rate in the 3 months following PRO survey completion did not differ by depression category (RR: 1.22; CI: 0.93-1.61). Conclusions: Over 13% of cancer patients report clinically significant depression during routine screening, which highlights the continued need for outpatient counseling and behavioral services. Although rates of inpatient admissions and ED visits were not impacted by the presence of depression, further analysis is needed to evaluate the impact of treating depression on healthcare utilization over time.
Universal hepatitis B screening in a high risk community.
Authors: Abraham Ivy , Mccullough Jane , Golick Janet , Cadman Kasandra , Cirignani Gay , Sta Maria Megan , Maynard Vera , Nelson Lupe , Nishimura Susan , Oremovich Elizabeth , Palma Lydia , Valero LeeAnn , Walker Maria , Zubel Stacey , Cuellar Sandra , Chacra Wadih , Venepalli Neeta K. 
Published: October 2019

244 Background: 2015 ASCO guidelines for Hepatitis B (HBV) screening in patients (pts) receiving chemotherapy recommend a risk-adaptive strategy considering patient and treatment-specific factors. The University of Illinois Cancer Center (UICC) is an academic center with largely underserved, minority and socioeconomically disadvantaged pts. UICC implemented a universal HBV screening policy in 2016. We aimed to increase HBV screening from 60% to 95% over 18 months. Methods: A multidisciplinary team of oncologists, hepatologists, fellows, nurses and pharmacists created an ideal process map for universal HBV screening in all pts starting chemotherapy outlining screening parameters, laboratory tests required and follow-up for positive screens. Four Plan-Do-Study-Act cycles were tested. Interim analysis was done targeting specific providers for additional education. Results of screening were analyzed by chart review. Results: A total of 589 treatment-naive pts were screened for HBV between Aug 2017 and Feb 2019. Educational sessions were held for nurses, pharmacists and fellows to review ideal process maps between Jan and March 2018. 0% of pts had insurance denials for HBV screening coverage. Screening rates improved from 65% in Aug 2017 to 100% in Feb 2019. Positive HBV screen rate was 3% (N = 18) and all were new diagnoses. 61% (N = 11) of positive screens had no risk factors for HBV exposure and would not have met risk adaptive criteria for screening. 27% (N = 3) of positive screens without prior risk factors were initiated on prophylactic ART. 50% (N = 9) of all new HBV diagnoses initiated prophylactic ART to prevent reactivation, while 50% received active surveillance on chemotherapy. 0% of pts on active surveillance developed reactivation. Conclusions: Implementing and sustaining a universal HBV screening program was feasible and effective in identifying pts at risk for reactivation in a high risk population. 61% of positive screens lacked traditional risk factors. Risk-adaptive screening may miss cases in diverse populations where HBV is not endemic, precluding appropriate management. Further evaluation will include expanding screening to inpatient chemotherapy starts and cost-benefit analysis of universal screening in this unique population.
A proactive approach to assess system safety in clinical operations at a comprehensive cancer center.
Authors: Durney Jeffrey , Wong Lawrence , Breaud Alan H. , Cedro Laura , Rowell Shannon , Harvey Caroline , Szabatura Audrea H , Kadish Sarah , Frank David , Lane Sharon , Lakhani Hakim , Bartel Sylvia 
Published: October 2019

245 Background: Traditional approaches to improve safety in clinical operations focus on reacting to adverse events and intervening at the process level to prevent recurrence. A need exists to proactively explore safety at the system level and evaluate human factors that lead to errors. We developed and piloted a system safety assessment methodology to identify vulnerabilities in the Research Pharmacy at Dana-Farber Cancer Institute. Methods: We developed an interview tool based on the human factors analysis and classification system (HFACS) to obtain staff member perspectives on safety vulnerabilities. Detailed process maps were created for safety critical processes. Policies, procedures, and job aids were evaluated for effectiveness at preventing errors. Interfaces between the Research Pharmacy and other areas were studied to identify potential expectation misalignment. These elements formed a comprehensive methodology to proactively assess safety threats. Results: Based on our application of the assessment methodology, 16 system safety vulnerability themes were identified (table below) and 44 recommendations were generated to address them. From the recommendations, 26 improvement projects were proposed to prevent the occurrence of safety events. To date, 15 projects addressing 13 safety vulnerabilities have been initiated. Conclusions: Vulnerabilities uncovered through our methodology can inform the development of projects to proactively reduce risk and improve system resiliency in any clinical setting. Preliminary data indicate longer average days between safety events in the Research Pharmacy as projects triggered by the assessment are implemented. Further analysis is underway. [Table: see text]