Chemotherapy Safety: Reducing Errors With a Nurse-Led Time-Out Process

Kimberly Kalo

Diana Karius

James F. Bena

Shannon L. Morrison

Nancy M. Albert

chemotherapy, drug administration, safety, medication error, patient safety
CJON 2019, 23(2), 197-202. DOI: 10.1188/19.CJON.197-202

Background: Nurses represent the last line of defense in preventing the occurrence of chemotherapy errors; it is important to assess error rates and implement quality improvement initiatives to reduce nurse-initiated chemotherapy administration errors.

Objectives: The purpose of this project was to assess the rates of chemotherapy administration errors before and after a two-nurse chemotherapy time-out process was implemented and the frequency of prevented errors in the postintervention and maintenance periods.

Methods: This retrospective quality report used pharmacy administration records and chemotherapy safety events to determine chemotherapy administration errors during three time periods.

Findings: The overall rate of chemotherapy administration errors was initially low (preintervention) and similar to published reports of error rates after interventions were applied to reduce error rates. The error rate remained low at the two postintervention assessment periods.

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