title: Using process elicitation and validation to understand and improve chemotherapy ordering and delivery.
abstract: BACKGROUND
  Chemotherapy ordering and administration, in which errors have potentially severe consequences, was quantitatively and qualitatively evaluated by employing process formalism (or formal process definition), a technique derived from software engineering, to elicit and rigorously describe the process, after which validation techniques were applied to confirm the accuracy of the described process.
  
  
  METHODS
  The chemotherapy ordering and administration process, including exceptional situations and individuals' recognition of and responses to those situations, was elicited through informal, unstructured interviews with members of an interdisciplinary team. The process description (or process definition), written in a notation developed for software quality assessment purposes, guided process validation (which consisted of direct observations and semistructured interviews to confirm the elicited details for the treatment plan portion of the process).
  
  
  RESULTS
  The overall process definition yielded 467 steps; 207 steps (44%) were dedicated to handling 59 exceptional situations. Validation yielded 82 unique process events (35 new expected but not yet described steps, 16 new exceptional situations, and 31 new steps in response to exceptional situations). Process participants actively altered the process as ambiguities and conflicts were discovered by the elicitation and validation components of the study. Chemotherapy error rates declined significantly during and after the project, which was conducted from October 2007 through August 2008.
  
  
  CONCLUSIONS
  Each elicitation method and the subsequent validation discussions contributed uniquely to understanding the chemotherapy treatment plan review process, supporting rapid adoption of changes, improved communication regarding the process, and ensuing error reduction.
authors.affiliation: Tufts University School of Medicine, Boston, USA.
authors.forename: Wilson C
authors.initials: WC
authors.lastname: Mertens
authors.forename: Stefan C
authors.initials: SC
authors.lastname: Christov
authors.forename: George S
authors.initials: GS
authors.lastname: Avrunin
authors.forename: Lori A
authors.initials: LA
authors.lastname: Clarke
authors.forename: Leon J
authors.initials: LJ
authors.lastname: Osterweil
authors.forename: Lucinda J
authors.initials: LJ
authors.lastname: Cassells
authors.forename: Jenna L
authors.initials: JL
authors.lastname: Marquard
mesh_terms: D001943:Breast Neoplasms / Q000188:drug therapy; D017024:Chemotherapy, Adjuvant / Q000379:methods / Q000592:standards; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008404:Massachusetts; D050316:Medical Order Entry Systems / Q000458:organization & administration* / Q000592:standards / Q000706:statistics & numerical data; D008508:Medication Errors / Q000009:adverse effects / Q000517:prevention & control* / Q000706:statistics & numerical data; D010348:Patient Care Team / Q000458:organization & administration* / Q000592:standards; D017064:Process Assessment, Health Care; D011785:Quality Assurance, Health Care / Q000379:methods / Q000458:organization & administration* / Q000592:standards