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Multisite parent-centered risk assessment to reduce pediatric oral chemotherapy errors.
Kathleen E Walsh1, Kathleen M Mazor, Douglas Roblin
1University of Massachusetts School of Medicine, USA. Kathleen.Walsh2@umassmemorial.org
Journal of Oncology Practice
|May 2, 2013
Summary
Parents of children with cancer partnered in a study using proactive risk assessment to identify and reduce errors in home oral chemotherapy administration. This approach successfully pinpointed key risks and informed new safety strategies.
Area of Science:
- Pediatric Oncology
- Patient Safety
- Medication Error Prevention
Background:
- Home oral chemotherapy use in children is associated with high error rates.
- Hospitals utilize proactive risk assessment to mitigate errors.
- Identifying home-based risks is crucial for pediatric cancer care.
Purpose of the Study:
- Engage parents in a multisite study using proactive risk assessment.
- Identify error occurrence in home oral chemotherapy administration for children with cancer.
- Propose risk reduction strategies with parental input.
Main Methods:
- Recruited parents from three pediatric oncology clinics for Failure Mode and Effects Analysis (FMEA).
- Utilized a systematic, team-based approach to identify process failures and develop prevention strategies.
- Focused on home oral chemotherapy administration post-dose change due to identified high-risk areas.
Main Results:
- Parent teams mapped the 13-step home chemotherapy process, identifying numerous failure modes.
- Key risks included miscommunication during clinician instruction and unsafe home handling of chemotherapy.
- Recommended strategies involved leveraging technology for improved access to information, clinicians, and peer support.
Conclusions:
- Parents actively engaged in proactive risk assessment for pediatric home oral chemotherapy.
- The study successfully identified high-risk processes and informed potential error reduction strategies.
- Parental involvement is valuable in enhancing the safety of pediatric cancer treatment at home.
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