Improving Chemotherapy Delivery for Pediatric Cancer Patients

More than 10,000 children in the United States are diagnosed with cancer annually, according to data from the American Cancer Society.1 However, rates of survival in this younger patient population have risen considerably across decades. The 5-year survival rates for childhood cancer were approximately 58% in the 1970s; today, they exceed 80%.1 These advances in treatment and survival are largely due to complex chemotherapy regimens, which have rendered once-deadly childhood cancers like leukemia and lymphoma treatable and even curable.2

Errors in delivery of childhood chemotherapeutic regimens can lead to serious adverse events, and even death in certain cases.3 Yet research has shown that due to the complex nature of pediatric regimens, the risk for error is high.4 Up to 7% of pediatric cancer patients treated in the outpatient medical setting experience errors in chemotherapy delivery, according to research published in Journal of Clinical Oncology.3 Researchers and treating physicians have noted the need for quality improvement in care delivery for this patient population.

Beginning in 2010, researchers from Cincinnati Children’s Hospital (Cincinnati, OH) have been studying the application of improvement science to reduce chemotherapy errors for childhood cancer patients. The researchers implemented specific measures related to chemotherapy delivery, including a chemotherapy near-miss reporting system; interventional models, including daily chemotherapy huddling and the use of headphones to reduce interruptions during chemotherapy ordering; and hospital-wide standards for chemotherapy ordering. In a paper published in Journal of Oncology Practice,5 the researchers reported a reduction in chemotherapy errors over the course of the program’s first 22 months, with sustained shifts from the baseline rate maintained for more than 4 years. Additionally, they observed a significant and sustained reduction in errors after 16 months of improvement implementation (P < .001).

Journal of Clinical Pathways spoke with Brian D Weiss, MD, director of the neuroblastoma program, associate director of the oncology research program, and associate director of safety and compliance at Cincinnati Children’s Hospital, regarding these advances, and the continued potential for improvement science’s utility across the field of childhood cancer treatment.

What type of errors are seen in childhood cancer treatment, and how common are they?

Our institution has a pretty strict definition of chemotherapy error. By that, I mean that there are some medications that could be given either orally or intravenously, or that could be given over the course of 15 minutes or 60 minutes. In cases like that, both are right. So we called an “error” any deviation from intention, even if that deviation was still technically correct. Another part of this is that what we are trying to avoid is the kind of error that occurred at Dana-Farber Cancer Institute in the mid-1990s, when the health journalist Betsy Lehman died after being given 5 days’ worth of chemotherapy in a total daily dose.6 That was what we would consider a major error, the kind of thing everyone tries to avoid.

The difference between a major error getting through and a minor error getting through is often just dumb luck. We started by considering prescription errors. I assumed that most errors we would see would be errors in the writing of prescriptions. But when we cast a broad net across all the things that can occur that deviate from intention, prescription errors were really a minority. None of the errors that we saw at our hospital rose above a Level C or Level D error, the latter of which is not life-threatening at all. But as I said, some of this is just dumb luck. If a Level C error can get through, something even more serious can likely get through.

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