Improving Patient Safety in the Inpatient Setting Through Risk Assessment and Mitigation

Maria Reche Navarro

safety, adverse event, adverse event management, risk management
CJON 2015, 19(1), 24-28. DOI: 10.1188/15.CJON.24-28

The care process for patients with cancer is particularly complex and affected by multiple factors that can impact patient safety. A detailed analysis of the entire care process allowed the author’s institution to identify critical points that affect patient safety and to implement safer practices. The treatment of patients with cancer is unique in that it requires numerous, successive, and interrelated interventions by different healthcare professionals (pharmacists, doctors, nurses, nursing assistants). These clinicians are responsible for the administration of antineoplastic chemotherapy, which requires special handling. These drugs (a) have a narrow therapeutic range, (b) are administered in varying doses, (c) are administered in protocols that combine multiple agents, (d) have doses and numbers of cycles that are variable, and (e) are often high in cost. The risk of high-severity medical errors is great with these agents, and adverse effects from errors are disproportionate to those from other drugs.

At a Glance

  • Identifying the magnitude and significance of risks to patients and clinicians is a key focus for assessment and improvement.
  • The author’s institution used the Oncology Patient Care Process, a catalog of adverse events, and developed a risk map of the cancer center to identify areas for improvement.
  • Making a graphic representation of the patient care process can help patients newly admitted to the inpatient unit.
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