Patient Safety Strategies for Oncology

High-quality cancer care requires safe and timely treatment. Failing to deliver appropriate care can have devastating consequences for cancer patients, who are particularly vulnerable to harm due to the nature of their illness, prescribed therapies, and care delivery.

In an analysis of medical oncology claims closed by The Doctors Company over a 12-year period, we identified three top allegations:

• Diagnosis-related (failure, delay, wrong) (30 percent).
• Improper treatment management (21 percent).
• Improper medication management (14 percent).

The strategies presented here can help oncologists keep their patients safe as they mitigate risks.

Avoid Allegations of Delay in Diagnosis or Treatment

Manage your patient through the treatment process to avoid possible delays in diagnosis or treatment. While careful tracking of lab tests and imaging results is important in all settings, lost results can mean lost time for cancer patients.

• Have an established laboratory and diagnostic test tracking system in place to ensure that results are received in a timely manner and patient follow-up is initiated. Having an effective process in place improves quality and reduces the likelihood of missed reports, patient harm, and liability claims.
• Implement a system that alerts you if a result or report is not received so that prompt follow-up can occur. Tracking systems should not depend on passively waiting for test results or a return appointment.
• Establish a process for notifying patients immediately when your office receives a panic value or abnormal test result. Document patient notification and actions taken.
• Do not file paper reports, tests, or correspondence of a clinical nature without the practitioner’s initials or signature and the date verifying that the practitioner reviewed the document.
• Sign off electronically on all results that come directly to the EHR.
• Follow a defined process for reviewing results that arrive while the practitioner is away from the office to avoid any delay in addressing results of an urgent nature.
• Use definitive diagnostic techniques and know the limitations of the tests ordered.
• Do not defer important tests because a patient is concerned about costs. If the patient refuses a test after being advised of its need and importance, document the patient’s refusal in the patient record. (For more information, see our article “Informed Refusal.”)
• Ensure timely referrals for challenges in diagnosis and treatment. These follow-up actions are cost effective and medically appropriate.

(For more information, see our article “Laboratory and Diagnostic Test Tracking in Ambulatory Practice.”)

Partner With the Pathologist

• Ensure that a defined process is in place for ordering pathology tests, collecting samples, and transporting samples to the testing facility.
• Provide the pathologist with adequate patient history and clinical information when a biopsy is requested.
• Alert the pathologist to any case in which the histology is sharply at odds with the clinical impression and ask to have the slides reviewed.

Partner With the Radiologist

• Provide the radiologist with adequate patient history and clinical information, including any comorbidities or medications that may affect the radiation therapy, to assist in determining the best treatment plan.
• Collaborate with the radiologist in effectively managing radiation side effects and monitoring skin care, nutrition, and hydration.

Ensure Medication Safety

Chemotherapeutic agents, which have narrow therapeutic ranges and are toxic even in the correct doses, require meticulous attention to detail in calculations and administration. Errors with these types of agents can have dire consequences. Consider the following strategies:

• Develop standardized preprinted medication order forms (paper or electronic) to help eliminate dosing errors, omission of critical set elements, and errors in sequencing and intervals.
• Train staff members who administer chemotherapy thoroughly, and document evidence of training.
• Monitor patients after chemotherapy/immunotherapy treatment, observing them closely for toxicity and complications. Respond rapidly, following a policy for emergent treatment as necessary.
• Never permit verbal orders to initiate or modify oncolytic therapy.
• Use a standard, routine method to calculate drug doses.
• Organize the patient record in a way that makes it easy for staff to confirm that all prerequisites have been met.

Consult the “Antineoplastic Therapy Administration Safety Standards for Adult and Pediatric Oncology: ASCO-ONS Standards” for specific guidelines on safe chemotherapy administration.

Develop a Culture of Safety

Cancer care is complex and, at times, hazardous work that requires careful attention to maintain safety for both patients and practitioners. The Agency for Healthcare Research and Quality has identified key elements in establishing a culture of safety:

• Acknowledge the high-risk nature of the organization’s activities and resolve to consistently achieve safe operations.
• Cultivate an environment that encourages reporting of adverse events and near misses without fear of reprimand or punishment.
• Encourage collaboration across ranks and disciplines to pursue solutions to safety problems.
• Commit resources to address safety concerns.

Establishing a fair and just culture is also important. While a culture of safety embraces human fallibility, a just culture does not dismiss clinician and staff accountability entirely—such as in cases involving a reckless or willful disregard of policies and procedures. Create a safe and just culture by addressing human errors through coaching or counseling (with zero tolerance for reckless behavior) and by concentrating on system issues that mitigate the risk of a similar error.

Creating a safe oncology environment is everyone’s responsibility. When the care team works together, it can create a safety culture that enhances the quality of care for oncology patients, decreases adverse events for patients and staff, and integrates a reporting system that allows adverse events, near misses, and improvement opportunities to be identified and studied.

For additional assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.