title: Improving cancer patient care with combined medication error reviews and morbidity and mortality conferences.
abstract: BACKGROUND
  To reduce the occurrence of medication errors, a systemic approach was developed combining anti-neoplastic medication error reviews and morbidity and mortality conferences (M&MCs). We report the first experience of implementing this strategy in oncology.
  
  
  METHODS
  The case reports submitted to combined reviews were prepared by physicians and pharmacists, and medication error(s) were described and chronological and root-cause analyses were performed.
  
  
  RESULTS
  Ten combined reviews were conducted, which involved the departments of haematology, medical oncology, pneumology, gastroenterology and clinical oncology pharmacy. A total of 91 errors were analysed, of which 3 had reached the patient. Thirty-four corrective actions were proposed; 53% consisted of changes in practice, 35% in procedural reminders and 12% in on-ward education sessions.
  
  
  CONCLUSIONS
  The combination of medication error reviews and M&MCs appears to be an efficient means of improving cancer patient safety and personnel proficiency. This multidisciplinary work is indispensable to improve future patient management through the critical analysis of past medical errors.
authors.affiliation: Department of Clinical Oncology Pharmacy, Groupement Hospitalier Sud, Hospices Civils de Lyon, Lyon, France.
authors.forename: Florence
authors.initials: F
authors.lastname: Ranchon
authors.forename: Benoît
authors.initials: B
authors.lastname: You
authors.forename: Gilles
authors.initials: G
authors.lastname: Salles
authors.forename: Nicolas
authors.initials: N
authors.lastname: Vantard
authors.forename: Vérane
authors.initials: V
authors.lastname: Schwiertz
authors.forename: Chloé
authors.initials: C
authors.lastname: Gourc
authors.forename: Noémie
authors.initials: N
authors.lastname: Gauthier
authors.forename: Marie-Gabrielle
authors.initials: MG
authors.lastname: Guédat
authors.forename: Pierre-Jean
authors.initials: PJ
authors.lastname: Souquet
authors.forename: Gilles
authors.initials: G
authors.lastname: Freyer
authors.forename: Véronique
authors.initials: V
authors.lastname: Trillet-Lenoir
authors.forename: Catherine
authors.initials: C
authors.lastname: Rioufol
mesh_terms: D000970:Antineoplastic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D003226:Congresses as Topic / Q000458:organization & administration*; D006785:Hospitals, University; D006801:Humans; D033183:Interdisciplinary Communication; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D009369:Neoplasms / Q000188:drug therapy*; D005791:Patient Care / Q000592:standards
chemical_list: D000970:Antineoplastic Agents