Patient Safety Strategies for Oncology

Lisa M. McCorkle, MSN, MBA, Senior Patient Safety Risk Manager, The Doctors Company

Cancer patients are at elevated risk for harm due to the nature of their illness, prescribed therapies, and care delivery. High-quality cancer care requires safe and timely treatment. If it is not provided, the results can be devastating.

In our analysis of medical oncology claims between 2012 and 2018, we identified three primary claim drivers:

• Diagnosis (failure or delay) (29 percent)
• Management of treatment (29 percent)
• Medication management (13 percent)

The strategies presented here are essential to enhancing patient safety and mitigating risk.

Ensure Medication Safety

Because chemotherapeutic agents have narrow therapeutic ranges and are toxic even in the correct doses, meticulous attention to detail in calculations and administration is required. 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, the 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 medical record in a way that makes it easy for staff to confirm that all prerequisites have been met.

Consult the “2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology” for specific guidelines on safe chemotherapy administration.

Track and Document Review of Lab Tests and Imaging Results

Handling test results is a critical task that is often cited in allegations against office-based practitioners. While careful tracking of lab tests and imaging results is important in all settings, lost results can mean lost time for cancer patients.

• 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 provider’s initials or signature and the date verifying that the provider reviewed the document.
• Sign off electronically on all results that come directly to the electronic health record.
• Follow a defined process for reviewing results that come in while the provider is away from the office to avoid any delay in addressing results of an urgent nature.

Partner With the Pathologist

• Ensure that a defined and reliable process is in place for ordering pathology tests, collecting samples, and transporting samples to the testing facility.
• Provide the pathologist with adequate 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 clinical information to assist in determining the best treatment plan, including any comorbidities or medications that may affect the radiation therapy.
• Partner with the radiologist to effectively manage radiation side effects and monitor skin care, nutrition, and hydration.

Avoid Allegations of Delay in Diagnosis and/or Treatment

• 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 medical record. (For more information, see our article “Informed Refusal.”)
• Use definitive diagnostic techniques and know the limitations of the tests ordered.
• Ensure timely referrals for challenges in diagnosis and treatment. These follow-up actions are cost effective and medically appropriate.
• Have an established test and diagnostic 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. It also mitigates patient harm and the possibility of liability claims.

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 providers. 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, it does not dismiss clinician and staff accountability entirely—such as in cases involving a reckless or willful disregard of policies and procedures. In a culture of safety, most human errors are addressed through coaching or counseling or through an emphasis 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 events and improvement opportunities to be identified and studied.

Find Help and Learn More

For more detailed education on teamwork, see our CME course TeamSTEPPS® Teamwork Training in the Office Practice. Our complimentary on-demand course provides an overview of the TeamSTEPPS® program’s concepts, tools, and strategies.

Learn additional lessons from our oncology study by accessing our on-demand CME course Analysis of Medical Oncology Claims. Our complimentary on-demand course explores the three drivers of malpractice claims and common contributing factors.

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

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