Improving pediatric chemotherapy safety through voluntary incident reporting: lessons from the field.
BACKGROUND
A multidisciplinary team within Vanderbilt Children's Hospital (VCH) designed, developed, and implemented a pediatric chemotherapy incident reporting and improvement system (CIRIS) for pediatric oncology nurse and pharmacists. The aim of this collaboration was to improve pediatric chemotherapy by translating recommendations made by the Institute of Medicine into an operational safety improvement system that is embedded into daily care processes.


METHODS
CIRIS improves chemotherapy safety by linking two distinct components: (a) a technical component that uses desktop, laptop, and portable wireless handheld computers to interface the Web-based software application for point-of-care incident reporting and on-demand retrieval of patient support information, and (b) a human component that performs process analysis, data reporting, and clinical improvement. This integrated system facilitates and supports a blame-free culture for reporting of near misses and preventable adverse drug events.


RESULTS
Between February 8, 2002, and March 9, 2003, pediatric oncology nurses and chemotherapy pharmacists electronically reported 97 chemotherapy-related incidents associated with 96 unique patients. Ordering errors were the most commonly reported incidents. CIRIS improved reporting performance demonstrated using the conventional paper-based reporting system.
France
Daniel J
DJ
Center for Improving Patient Safety, Vanderbilt University Medical Center, Nashville, TN, USA. dan.france@vanderbilt.edu
Cartwright
Julia
J
Jones
Vicki
V
Thompson
Vicky
V
Whitlock
James A
JA
D000970:Antineoplastic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D002648:Child; D005260:Female; D006751:Hospital Information Systems; D006776:Hospitals, Pediatric / Q000592:standards; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000517:prevention & control*; D008510:Medication Systems, Hospital / Q000592:standards*; D015397:Program Evaluation; D012308:Risk Management / Q000379:methods / Q000458:organization & administration*; D013714:Tennessee
D000970:Antineoplastic Agents