Raising the safety bar: The hematology/oncology patient safety committee.

Authors

null

Myrna Rita Nahas

Beth Israel Deaconess Medical Center, Boston, MA

Myrna Rita Nahas, Jessica A. Zerillo, Stephen A. Cannistra, Cheryle Totte

Organizations

Beth Israel Deaconess Medical Center, Boston, MA

Research Funding

No funding sources reported

Background: Enhancing patient safety can prevent unintended outcomes arising from defects in healthcare delivery systems. The Hematology/Oncology Patient Safety Committee (HOPSC) at Beth Israel Deaconess Medical Center (BIDMC) is a multidisciplinary team of healthcare providers that meets monthly to review inpatient and outpatient adverse events, near misses, and medical errors that impact patient safety. Methods: Our aim was to quantify and qualify the cases that the HOPSC has reviewed from 2012-2013. In order to identify trends in event reporting, we reviewed the number of events reported to the HOPSC in both the inpatient and outpatient settings. We further subdivided events into two categories: medication-related and non-medication related. Additionally, we delineated which healthcare provider initiated the reporting of each event. Results: Over the two-year period, a total number of 1,061 events were reported to the HOPSC. Of these, 259 were medication-related events. Of the events reported, 40 were by a physician/NP and 1,021 were by a nurse. There was a discrepancy in the type of event reported (24.4% medication vs. 75.6% non-medication related) as well as in the type of reporter (3.8% physician/NP vs. 96.2% nurse). Of all the events reported, 8 were escalated to the Department of Medicine Peer Review Committee. Conclusions: Through review of healthcare provider event reports, the HOPSC has identified several types of adverse events and near misses in the Hematology/Oncology division at BIDMC. The events are mostly reported by inpatient nurses and are primarily medication-related. Given this skewed reporting pattern, we will investigate the reasons why reporting by physicians, especially in the outpatient setting, is limited. Our reported outline of the HOPSC operations may also guide oncology practices elsewhere in their own development of patient safety peer review committees.

Adverse event reporting.
Reporting provider
Outpatient
Inpatient
Adverse event/near miss/medical error Medication Nonmedication Medication Nonmedication
MD/NP 0 10 6 24
Nurse 40 170 211 532

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Abstract Details

Meeting

2014 ASCO Quality Care Symposium

Session Type

Poster Session

Session Title

General Poster Session B: Cost, Value, and Policy in Quality and Practice of Quality

Track

Practice of Quality,Cost, Value, and Policy in Quality

Sub Track

Patient Safety

Citation

J Clin Oncol 32, 2014 (suppl 30; abstr 144)

DOI

10.1200/jco.2014.32.30_suppl.144

Abstract #

144

Poster Bd #

F12

Abstract Disclosures

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