bluuebunny/crossref_metadata_2025_split huggingface dataset:
Utilizing a two nurse timeout process to eliminate errors during chemotherapy administration.
Authors: Hooley Joseph , Karius Diana , Colvin Christina , Akins Patti , Best Carolyn , Brinker Allyson 
Published: September 2018

237 Background: Chemotherapeutic agents are listed as high risk medications at Cleveland Clinic, and have long been included on the Institute for Safe Medication Practices (ISMP) List of High Alert Medications due to the heightened risk of causing significant patient harm if they are used in error. Following a series of significant adverse events involving chemotherapy administration in 2012 at Cleveland Clinic, a two nurse timeout process (modeled after surgical and procedural timeout practices) was established to eliminate interruptions and decrease the risk of error. Methods: A written protocol was established to formalize a two nurse timeout process which must be completed prior to administration of chemotherapy. In order to eliminate unnecessary distractions during order review and medication administration, nurses hand off their phone and/or pager and coverage is provided for the nurses who are checking in the chemotherapy. A designated distraction-free area is utilized chemotherapy verification and order review. Following comparison of the chemotherapy agents to the orders, the nurses proceed to the patient’s room with the chemotherapy and the order pulled up on a computer. A procedure stop sign is placed on the door and the door is closed to eliminate interruptions. During the in-room timeout process, each step in the chemotherapy documentation flow sheet is reviewed by both nurses. After proper patient identification, one nurse will read the chemotherapeutic agent label and the other nurse will program the infusion pump. The two nurses will then switch roles with re-verification of the label and the infusion pump. The tubing set-up is then verified and the infusion is initiated. Results: Since the two nurse timeout process was established in 2013, there have been zero serious chemotherapy errors resulting in patient harm. Conclusions: Results have shown that implementation of the chemotherapy timeout process has increased the safety of administration of chemotherapeutic agents. It has now been more than five years since the last significant adverse event involving chemotherapy has occurred at Cleveland Clinic.
Steroid tapering for patients with spinal cord compression or symptomatic brain metastases at Jackson Memorial Hospital.
Authors: Asher David , Farnia Benjamin , Ramey Stephen , Francis Sarah , Mehta Shahil , Richardson Angela , Manzano Glen , Samuels Stuart , Yechieli Raphael 
Published: September 2018

238 Background: Metastases to the spinal column and brain for patients with cancer are common occurrences seen in oncology practices. Steroids play a critical role in symptom management upon patient presentation and proper tapering of steroids is necessary to minimize risk of recurrent symptoms. Within our institution, which is a tertiary care facility primarily for the poor and near-poor of a large urban environment, 78% of patients with spinal cord compression or symptomatic brain metastases do not receive appropriate tapering of steroids following completion of radiation treatment. This leads to unnecessary side effects from continued steroid use, ultimately leading to an inefficient use of resources, including time and money. Methods: Through the guidance of American Society of Clinical Oncology (ASCO) Quality Training Program, we created a process map, cause and effect diagram, and acquired preliminary diagnostic data. This data was acquired via electronic medical record (EMR) review including evaluation of inpatient notes, discharge summaries, medication orders and prescriptions, and outpatient clinic visit notes. We then completed several PDSA cycles including grand round presentation, tapering template incorporation into clinic, and template creation within our EMR. Results: We identified that a single physician primarily was responsible for the patients that appropriately received steroids. We utilized this physician's expertise to help create meaningful interventions. By the complete of our last PDSA cycle, we have reduced the percentage of patients who do not receive an adequate steroid taper form 78% to 20%. Conclusions: Practitioner education and incorporation of steroid tapering templates into an outpatient radiation oncology clinic can reduce the percentage of patients with spinal cord compression or symptomatic brain metastases, who do not receive and adequate steroid tapering regimen.
Clinical decision support to reduce laterality ordering errors for breast imaging procedures.
Authors: Hernandez Karen , El-Tamer Mahmoud , Gurman Jonathan , Moulder Robin , Nevrekar Reshma , Robinson Donna , Sarwan-Vega Kimberly , Granovsky Svetlana 
Published: September 2018

241 Background: Data showed 46 modifications to breast imaging orders upon patient arrival to the Radiology Department, in a 4 month period (Sept-Dec 2014.) Upon further investigation, we found that patients were arriving in radiology, scheduled for exams for which the laterality needed to be modified prior to the exam. (The most frequent occurrence was a patient with a history of a unilateral mastectomy, arriving in radiology for a bilateral mammogram.) These laterality order errors were traced back to either the referring LIP requesting the exam, or to the referring office’s clerical staff transcribing the order. The ordering errors came from many different referring services. Methods: Our objective was to develop Clinical Decision Support in our Clinical Information System (CIS,) to offer an upfront alert of a potentially incorrect laterality when a user was entering or transcribing an order, prompting the user to confirm that the correct exam had been ordered before scheduling took place. The Health Informatics team developed a Medical Logic Module (MLM) in CIS which cross-checks the surgical history in the Clinical Documentation Operative Notes with the current CIS order; if a mismatch is found, the alert fires. Results: In the first 2 months (Dec 2016-Jan 2017), 110 alerts were generated. Fifty-seven alerts flagged users of incorrect orders which were corrected before being scheduled; 21 MLM alerts were acknowledged and comments entered explaining the need for the test; 32 alerts did not generate an order (and in most of these instances, the user backed out and entered the incorrect order again; upon the second time seeing the alert, they changed the order, resulting in many of the 57 changed orders referenced above). Conclusions: The MLM alert allows for immediate feedback to the user entering an order with a potentially incorrect laterality. Not only does this reduce the time and burden associated with investigating and modifying these orders upon patient arrival; more importantly, it ensures orders are entered correctly from the start, reducing the possibility of an incorrect exam taking place.
Medical error reporting, culture, and infrastructure.
Authors: Denny, DBA Diane , Shinners Caitlyn 
Published: September 2018

245 Background: Much work has focused on the importance of culture as a key factor in advancing the patient safety discussion. No assumption can be made that a culture of safety equates to embracing responsibility to report when errors and near misses occur. Underreporting exists. Without data, the opportunity to redesign care and address system failures is diminished. This research aimed to answer: what impact do various factors have on influencing the likelihood of reporting across a hospital network of oncology providers? Methods: The AHRQ Hospital Culture on Safety was used coupled with 15 custom questions of interest. Dependent variables (DVs) included: structure for reporting (definition, policy and ease), incentives to report, supervisor/employee relationship and management support. Independent variables (IVs) included number of errors reported and perceived frequency by which events are reported, influenced by tenure and extent of patient interaction. Higher scores associated with the IVs were posited to be positively associated with the errors reported as well as the reporting frequency. A principle component analysis was conducted as a variable reduction technique to affirm factors; the reliability of factors tested; and multiple regression analyses conducted to test the strength of relationships. Results: 2,103 surveys were completed. The 4 factors are found to weakly predict the DVs. Infrastructure had the greatest association in both models. Tenure and patient interaction influenced the likelihood of reporting. Conclusions: This research moves beyond culture in ascertaining factors pivotal in the underreporting of errors and near misses. An infrastructure promoting reporting must also exist ensuring staff know what, how, when, and why to report, linking data to action.[Table: see text]
Sustaining operational excellence in the oncology intensive care unit.
Authors: Barniak Sharon , Leahy Jennifer , Brash Jason , Wright Dana , McGovern Joanne 
Published: September 2018

248 Background: In a high risk setting such as an oncology Intensive Care Unit (ICU), providing quality care and maintaining a culture of safety is vital to patient outcomes. Operational excellence built a foundational operating framework in the ICU, created process reliability and connected value streams through standardization, while increasing value to patients and employees. The purpose of this investigation was for the ICU and operational excellence teams to examine and eradicate defects. Five areas: Safety, Quality, Engagement, Innovation/Finance were determined to be most impactful and aligned with the unit’s key performance indicators. Metrics centered on patient safety and hospital-acquired complications (VTE, HAPU, VAE’s and CLABSI) became the focus of data collection and daily discussion. Methods: A multidisciplinary team designed and implemented a Lean Daily Management Board based on five predetermined metrics. The team met daily for a brief huddle to review a checklist confirming documentation adherence, patient outcomes, productivity, and employee engagement. Fallouts are addressed using a problem solving tool, displayed for awareness and corrective measures. Results: Initial data collected starting in January 2014, noted medication scan rate of 75%, fall rates at 1.32/1000 patient days, VTE 77%, HAPU 1/1000 patient days, VAE’s 1/1000 patient days, and CLABSI 0.3/1000 patient days. Continuing education and certifications among nurses were not defined at baseline. After implementation of the Lean Daily Management Board, 2015 data revealed an increase in medication scanning to 98.9% and 99.05% in 2017. Fall rates remain consistent at 1/1000 patient days and VTE prophylaxis climbed to 100% in 2015 and through 2017. HAPU’s decreased to 0.6/1000 patient days, and VAE’s were reduced to 1 in 2015, 0 in 2016 and 2017. CLABSI rates decreased to 0. Nursing certifications rose from 28% to 62% in 2017. Conclusions: Lean daily management empowered the staff to drive quality and safety in the ICU. Deficiencies fostered accountability and implementation of evidence-based patient care practices. Process improvement, positive patient outcomes, and increasing nurse engagement were achieved utilizing operational excellence.
Identifying potentially preventable emergency department (PPED) visits among patients with cancer in Ontario.
Authors: Yao Jane , Green Bo , Krzyzanowska Monika K. 
Published: September 2018

25 Background: Cancer patients (pts) often visit the emergency department (ED) when symptoms and side effects occur. Growing evidence suggests that some treatment-related toxicities can be managed proactively in outpatient clinics, improving patient experience and optimizing acute care utilization. Understanding PPED visits is crucial to developing and evaluating such improvement efforts. Our objectives were to quantify the extent of PPED visits in Ontario among cancer pts and identify the best measure of PPED for province-wide quality improvement. Methods: By linking Activity Level Reporting to the Discharge Abstract Database and the National Ambulatory Care Reporting System, we identified cancer pts who had ED visits or hospitalizations up to 30 days after receiving chemotherapy and/or radiotherapy from April 1, 2014 to March 31, 2015 in Ontario. Episodes were stratified as ED Only or Indirect Admission (ED visit leading to hospitalization). We mapped the presenting Canadian Emergency Department Information System (CEDIS) complaints against the PPED metric proposed by Panattoni et al (JOP, 2018) that combined the CMS preventable visits typology with the STAR PRO tool (Basch et al, JCO, 2016) which found 49.8% were considered potentially preventable (PP). Results: We identified 43,593 ED visits (67% ED Only& 33% Indirect Admissions) among 64,407 pts. The most common presenting CEDIS complaints were pain (20%), fever (13%) and shortness of breath (SoB, 7%) among chemotherapy pts, and pain (19%), SoB (11%) and general weakness (9%) among radiotherapy pts. By applying the CEDIS-based PPED definition, which includes 17 presenting complaints, 50% of ED Only and 68% of Indirect Admission visits were considered PPED. Conclusions: We were able to adapt the PPED algorithm for the Canadian context, which can aid cross-jurisdiction comparisons. We found a substantial proportion of PPED visits. While common presenting complaints had face validity for being PP and a similar proportion of visits were PP compared to the US-based definition, further validation of this approach against healthcare records and in other jurisdictions would be helpful as these metrics become increasingly used for quality improvement.
Oral chemotherapy education sessions at an academic and community cancer center.
Authors: Roberts Daniel Aaron , Doolin Jim , Cibotti Christina , Hartwell Rebekah A , Yenulevich Mary , Trillo Kelsey , Hamdan Ayad , Rodrigues Christopher , Smith Morgan Brittany , Dowling Holly , Tocci Noah Xavier , Devlin Scott M , Shea Meghan , Zerillo Jessica A. 
Published: September 2018

254 Background: Oral chemotherapy is becoming more widely utilized within oncology. Concerns regarding poor adherence and toxicity may be addressed by providing patient education. Methods: We developed and implemented a pharmacist-led initial education session for patients newly prescribed oral chemotherapy in both an academic medical center gastrointestinal oncology clinic and an affiliated community oncology cancer center. We provided an education packet including drug-specific information, clinic contact telephone numbers, and a drug schedule calendar. Standardized teaching and documentation templates were used. Patients completed each education session with the MOATT teaching tool for patients receiving Oral Agents for Cancer V1.2. Assessment of compliance with the ASCO/ONS Chemotherapy Administration Safety Standards on Oral Chemotherapy Education was assessed through use of Quality Oncology Practice Initiative (QOPI) quality measures where applicable and compared to historical QOPI data from the academic medical center from 2015-2017. Results: Thirty-one patients were newly prescribed oral chemotherapy and received the initial education session from November 2017 through May 2018. Based on a monthly report generated of new oral chemotherapy prescriptions, after a seven-month run-in, the rate reached 100% of patients at both sites for the most recent month. When comparing the intervention cohort to the historical QOPI cohort using a one-sided P value of 0.017 with bonferroni correction, there was improvement in safe handling/storage (pre: 19%, post 100%, P = 0.0001), drug-drug and food interactions (pre: 31%, post 100%, P = 0.0001), and plan for missed doses (pre: 37%, post: 97%, P = 0.0001). A trend toward improvement was found for schedule/start date discussion (pre: 87%, post: 100% P = 0.018) and side effect/toxicities (pre: 87%, post: 100% P = 0.018). Conclusions: Implementation of an oral chemotherapy education session in both an academic and community setting was feasible and improved adherence to QOPI measures of oral chemotherapy education and ASCO/ONS standards for oral chemotherapy. Further data regarding time to clinical outcomes is forthcoming.
Trends in aggressive inpatient care at the end-of-life for stage IV lung cancer patients.
Authors: Mrad Chebli , Abougergi Marwan S , Daly Robert Michael 
Published: September 2018

26 Background: Metastatic lung cancer patients are treated with palliative intent. Aggressive inpatient care at the end-of-life is seen as a marker of poor quality care. However, national trends and factors related to aggressive inpatient care at the end-of-life for these patients have not previously been evaluated. Methods: A total of 3,030,866 hospitalizations of metastatic lung cancer patients were identified in the National Inpatient Sample database between 1998 and 2014. Longitudinal analysis was conducted to determine trends in aggressive inpatient care at the end-of-life and multivariate logistic regression was performed to determine associations with age, race, region, and hospital characteristics. Results: From 1998 to 2014, in-hospital mortality for metastatic lung cancer patients decreased from 17% to 11%. However, the proportion admitted to the intensive care unit during the terminal hospitalization increased from 12.9% to 26.4%. Reflecting this aggressive end-of-life care, mean total charges for a terminal hospitalization increased from $29,386 to $72,469, adjusted for inflation. Among patients who died in the inpatient setting, the intensive care unit stay translated into higher total costs (+$18,461 CI: $17,460 to $19,463). Promisingly, palliative care encounters for terminal hospitalizations increased during this period from 8.7% to 53.0% and were correlated with a decrease in aggressive care at the end-of-life. A multivariable model showed variation by patient and hospital characteristics in aggressive inpatient care utilization. Conclusions: Among patients with metastatic lung cancer there has been a substantial increase in intensive care unit use during terminal hospitalizations, resulting in high cost for the health care system.
Enhancing safety and delivery of oral chemotherapy utilizing lean methodology.
Authors: Fernandez Debbie , Hulen Kathy , Scott Leigh Anne , Bambara Kelsey , Creamer Gayle , Wright Jeff , Tsue Terry , Neiberger Adam , Hoffmann Marc Steven 
Published: September 2018

266 Background: An oral chemotherapy safety event prompted analysis of related workflows utilizing lean quality improvement methodology. This analysis identified high variation in prescription processing, lack of standardized safety checks, inefficient use of pharmacy time, and inadequate data collection. Our goal was to create an oral chemotherapy protocol that could ensure patients have the right oral chemotherapy agent, at the right dose, at the right time, with independent and efficient safety checks by nursing, pharmacy, and providers. Methods: Multidisciplinary teams participated in two kaizen workshops. utilizing lean methodology. Primary workshop objectives were (1) develop safety standards for oral chemotherapy similar to those for intravenous chemotherapy; (2) make workflows more efficient; and (3) have workflows that enable data collection and process control. The first workshop standardized oral chemotherapy prescription processing though a single workflow in the EMR. This enabled robust data collection and established a platform for safety interventions. The second workshop developed standardized safety checks for and integrated those into the EMR workflow. Given the rarity of serious safety events, a validation measurement was not feasible to track in 30-day PDCA cycles. Consequently, surrogate measures of utilization of the EMR prescribing algorithm and reduction of non-clinical pharmacy interventions were used to assess progress. Safety data were collected and correlated to surrogate outcomes for long-term impact assessment. Results: Interventions resulted in the following outcomes: 100% reduction in oral chemotherapy order defects reaching pharmacy; 97% improvement processing oral chemotherapy though a single EMR workflow; 23% reduction in oral chemotherapy processing time; In spite of a 51% increase in oral chemotherapy volume, no serious safety events have occurred in the last year. Conclusions: Comprehensive quality improvement in our oral chemotherapy process increased safety and efficiency while developing data collection systems for continuous improvement. Multidisciplinary workshops with key stakeholders using established lean methodology were critical to success.
Reducing opioid utilization after urologic oncology surgery.
Authors: Stevenson Kerri , Kee Jessica , Van Zyl Elizna , Dugala Anisia , Shah Jay Bakul 
Published: September 2018

269 Background: Multiple sources have reported on widespread abuse of opioid pain medications among Americans. For many patients, the first encounter with these addictive substances happens when they are prescribed opioids for acute pain management after surgery. Unfortunately, 6% of opioid-naïve patients become newly addicted to opioid medications after surgery. As a high-volume surgical department, we aimed to reduce our reliance on opioid medications to manage post-operative pain by 50% from a baseline morphine equivalent daily dose (MEDD) of 95.1 to a target of 47.5 MEDD. Methods: We retrospectively reviewed daily opioid use, pain scores, and anxiety scores for inpatients recovering from surgery for urologic cancers at our institution over 4 months. We generated process maps, Ishikawa diagrams, and Pareto charts to identify causes contributing to excess opioid use. We designed opioid-sparing pain regimens (using varying combinations of acetaminophen, ketorolac, gabapentin, and local anesthetic) and we identified key drivers required to reliably decrease excess opioid use. Initial interventions were aimed at educating providers and nurses on availability and efficacy of non-opioid medications and later interventions sought to facilitate adoption of the novel pathways. Results: Over the course of this QI project involving 443 patients, the median opioid use per patient decreased 46% from 95.1 to 51.5 MEDD. This reduction in opioid requirements after implementation was successfully achieved across multiple surgery types ranging from robotic prostatectomy (55.1 MEDD) to open radical cystectomy (50.6 MEDD). There was no increase in 24- or 48-hour post-operative pain score associated with use of opioid-minimizing pathways (3.03 vs. 3.04 and 2.92 vs. 2.96, respectively; p > 0.05 for both). Similarly, there was no change in anxiety score at 24- or 48-hours after surgery (0.15 vs. 0.12 and 0.48 vs. 0.30, respectively; p > 0.05 for both). Conclusions: We decreased opioid use after surgery by 46% without compromising pain control. In the nationwide effort to combat the opioid epidemic, health care providers can play a pivotal role as gatekeepers by decreasing reliance on opioids in the post-operative period.