Because of their complex environment of care, oncology practices and hospital oncology programs are microcosms for creating the culture of safety embedded in the National Patient Safety Goals.

Cancer diagnosis is complex, and technological advances increase that complexity. Chemotherapy options are elaborate and often associated with high risk, sometimes involving experimental treatment. Attitudes and emotions surrounding cancer are complicated and vary widely from patient to patient and physician to physician. Patients may be in pain or have multiple social needs. Each layer of complexity is not merely additive; rather, it is exponential.

While no program can eliminate all possibility of error, there is a paradigm of processes, people and philosophy that can maximize safety for oncology services.

The philosophy begins with defining the scope of services. It would be a mistake for every cancer treatment program to say it can safely handle everything. Patients with highly specialized needs, like pediatric hematologic oncology, should be referred to regional centers.

Community hospitals and community physicians, however, have a fundamental role to play in delivering quality oncology services in facilities close to patient homes and support networks. An integrated local oncology program can provide safe, seamless care from initial diagnostics through post-discharge follow-up, enhancing safety by keeping the patient’s local physician central to management of the case.

This helps avoid multiple hand-offs that provide opportunities for miscommunication and that often create delays. Where local hospitals have quality imaging systems like PET/CT and high imaging MRI, local physicians need not send patients out for diagnostic imaging that can identify disease earlier and pinpoint tumors for treatment planning. PACS systems allow hospital-based radiologists to share imaging with referring physicians and provide real-time consultation without transferring physical files. When hospitalization is required, there is no substitute for a dedicated oncology unit, whether the patient is post-surgical or undergoing chemotherapy. Specialized certified oncology nurses are uniquely qualified to manage complex treatment regimes where the risks of errors are high.

Cytostatic drugs are extremely powerful — the smallest error can have profound consequences. Oncology nurses working with standard protocols can reduce many of the risks presented by look-alike and sound-alike drugs, nonstandard dosages, illegible handwriting and infusion pump safety. Many oncology units have instituted “no telephone order” policies, and we expect to see more hospitals adopting policies for “no handwritten orders” in chemotherapy.

Because most cancer patients, regardless of their primary means of treatment, are immuno-compromised, every oncology program’s patient safety initiatives must have a focus on infection control. Equipment like DaVinci surgery robotics assists with infection control by offering minimally invasive surgical options. The availability of private rooms for oncology patients not only reduces exposure to potential hospital-acquired infection but create more opportunity for patient and family education before discharge, potentially reducing avoidable readmission.

Comprehensive community oncology programs also must use rigorous quality control and patient safety procedures in radiation oncology. Availability of treatments like seed implants for prostate cancer, Mammosite HDRT for breast cancer and Image Guided Radiation Therapy offers many opportunities to reduce treatment times, improve accuracy and limit damage to surrounding tissue.

Each of these is a tool in improving patient safety. New to the National Patient Safety Goals list for 2007 is a specific requirement that hospitals assess every patient in terms of risk for suicide. When faced with a cancer diagnosis, some patients tragically feel that suicide is their best option. Physicians must partner closely and frankly with hospitals in assessing each patient’s risk and work to align resources and interventions appropriately. The critical success factor for patient safety in oncology services remains communication. There needs to be communication between the patient and physician, the physician and the treatment team, and across disciplines.

The National Patient Safety Goals articulate objectives for communication at hand-off between levels of care or caregivers, and many hospitals will focus on documentation. The best programs will focus on the communication itself.
Paul Beaupré, M.D., is Chief Medical Officer and Chief Operating Officer for Good Samaritan Hospital in San Jose.

Posted on April 23, 2007 11:09 AM