Kylie Tierney

Reducing Chemotherapy Administration Errors in a Hematology/Oncology Unit

BACKGROUND: Nurses are the last barrier to detecting errors in the chemotherapy administration process. Currently, nurses on a 39-bed inpatient hematology/oncology unit with hematopoietic stem cell transplant patients perform a chemotherapy time-out before administering chemotherapy or commencing a chemotherapy regimen. Nurses typically perform this time-out in the hallway or at the nurses’ station but frequently experience interruptions such as call lights, phone calls, and conversations from others in the hallway. This project aimed to reduce chemotherapy administration errors by implementing a “Do Not Disturb Zone.” METHODS: The Iowa Evidence-Based Practice Model was used to develop and implement a Do Not Disturb Zone. Errors were reported via Midas incident reporting system and used to measure the number of chemotherapy administration errors. A pre- and post-implementation survey was distributed via Microsoft Forms to qualitatively measure nurses’ perceptions of interruptions and distractions on chemotherapy safety, as well as conducting a small focus group. INTERVENTION: A Do Not Disturb Zone was implemented over the course of 12 weeks in a centralized, quiet location for nurses to perform the chemotherapy time-out. RESULTS: Pre- and post-implementation surveys had a response rate of 72% and 59%, respectively. The compliance rate was 67%, with an overall decrease in the number of chemotherapy administration errors in the twelve weeks compared to previous quarters. CONCLUSIONS: Findings include statistical significance regarding nurses’ confidence in the administration of chemotherapy, awareness of distractions and impact on errors, as well as a decrease in the frequency of distractions. The project's specific aims were achieved and the clinical significance was great as preventing even just one chemotherapy error, prevents significant patient harm or death.

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