C hemotherapy S afety I nitiative: Solving the Puzzle for Safer Administration

1. Chemotherapy Safety Initiative: Solving the Puzzle for Safer Administration Kimberly Gross, MSN, RN, CPON; Stephanie Powell, MSN, RN, CPON; Beth Storey, MSN, RN, CPON; Patricia Danz, BSN, RN, CPON; Megan Henning, BSN, RN, CPON; Jennifer Bish, BSN, RN; Cynthia Reilly, BSN, RN, CPON; Mira Manek, The Children’s Hospital of Philadelphia Measures PDSA Cycles Background • Educated staff at the 2009 Nursing Skills Fair. • Administered a post skills fair survey to assess knowledge of new practices. • Implemented an outpatient to inpatient hand-off process. • Created and implemented a new flow sheet in the outpatient clinic to improve documentation. • Utilized visual reminders for policy changes. • Provided real-time one-to-one feedback by auditors. Chemotherapy administration errors can cause serious harm to patients. In order to prevent such errors, it is important for nurses to utilize consistent practices across the continuum of care. Through the Oncology Quality Improvement and Chemo Safety Committees, trends in both actual and potential nursing administration errors related to chemotherapy were revealed. In an effort to address these trends, a group of inpatient and outpatient nurses, led by Improvement Advisors from The Office of Patient Safety and Quality, formed a Quality Improvement team. The team embarked on a project called Chemotherapy Safety Initiative (CSI). Numerous Plan-Do-Study-Act (PDSA) cycles were implemented and evaluated for every process measure. Monthly chart audits take place to measure for improvement. Barriers • Difficult to influence change in a large group when introducing multiple changes at once. • Hospital’s High Alert Medication (H.A.M.) policy was changed mid-project , which impacted the process. • Current computer system has limited documentation capabilities to support policies . Aim Nursing practice rate of compliance related to safe chemotherapy administration will increase to 90% by December 2010. Lessons Learned • Consistency in nursing practice improved across the inpatient and outpatient setting. • Communication improved and a stronger partnership was created due to inpatient and outpatient collaboration. • Nursing practice rate of compliance related to chemotherapy administration increased. • The quality improvement team process positively impacted patient safety. Objectives • Improve nursing documentation related to: • 2 RN chemotherapy sign out • Stop time for infusions > 1 hour • 2 RN documentation per the hospital High Alert Medication policy