Hand Hygiene Compliance at a Canadian provincial cancer centre - the complementary roles of nurse auditor-driven and patient auditor-driven audit processes and impact upon practice in ambulatory cancer care.

BACKGROUND: We examined the patterns of hand hygiene compliance (HHC) among health care providers (HCP) as observed by trained nurse and patient auditors over time in an ambulatory care Canadian provincial cancer agency. METHODS: Nurse and volunteer patient auditors completed separate standardized forms documenting hand-cleansing opportunities during clinic visits. HHC rates were compared over time by HCP group and by specialty teams. Observations from 10 calendar quarters were analyzed from April 2015 to September 2019. RESULTS: Nurse audit HHC rates ranged from 84% to 96%, encompassing 7,213 opportunities with no significant time-dependent trends by linear regression (R2 = 2.3E-005, P = .9895). The patient audit HHC rates ranged from 57% to 82%, encompassing 23,402 opportunities, were lower overall compared to the nurse audit (73.6% vs 89.2%, respectively, P < .0001), but displayed an increasing trend (R2 = 0.5374, P = .0159) over the same 10 time periods. The relative risk ratio for the differences decreased over time (R2 = .5101, P = .0203). Patients acknowledged the importance of HHC and the audit process, but were reticent to remind HCP to comply. CONCLUSIONS: The nurse audit measuring HCP HHC before entering and after exiting patient examination rooms showed persistently high compliance over time whereas the patient-driven audit measuring HHC within the examination room increased over time suggesting a training effect upon practice. These measures appeared complementary.

Developing recommendations for the safe handling of oral anti-cancer drugs in community pharmacies: A pan-Canadian consensus approach.

PURPOSE: To create a set of consensus-based and evidence-informed recommendations to provide guidance around the safe dispensing and handling of oral anti-cancer drugs in low-volume settings unique to the community pharmacy setting. METHODS: A review of published and grey literature (published in non-commercial domains such as national organizations and associations) documents and nine key informant interviews were conducted and a modified Delphi approach was taken to achieve consensus. The final list of 47 candidate recommendations was reviewed by a task force and validated by multi-disciplinary stakeholders. A draft of the statements was circulated broadly within the community pharmacy community in an effort to assess relevance and implementation feasibility. RESULTS: The final report included 44 recommendations that addressed 11 key areas germane to the safe handling of oral anti-cancer drugs in community pharmacies. Mean agreement increased from 70% to 95%. Early feedback from community pharmacy leaders during the external review suggests that many of the proposed recommendations can be feasibly implemented within a reasonable timeframe when released with appropriate education and resource materials. CONCLUSIONS: A modified-Delphi approach supplemented by key informant interviews and a comprehensive external review resulted in a set of evidence-informed, community-driven recommendations for community pharmacies. The recommendations address a gap in existing literature to improve understanding of the risks associated with handling and dispensing oral anti-cancer drugs for both community pharmacy staff and management and offer mitigating strategies to reduce those risks. Incorporating feasibility assessment actions early (through the key informant interviews) and late (through the external review) ensures recommendations are grounded in practicality and support broad and early knowledge translation strategies.

Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study.

PURPOSE: Intravenous (IV) compounding safety has garnered recent attention as a result of high-profile incidents, awareness efforts from the safety community, and increasingly stringent practice standards. New research with more-sensitive error detection techniques continues to reinforce that error rates with manual IV compounding are unacceptably high. In 2014, our team published an observational study that described three types of previously unrecognized and potentially catastrophic latent chemotherapy preparation errors in Canadian oncology pharmacies that would otherwise be undetectable. We expand on this research and explore whether additional potential human failures are yet to be addressed by practice standards. METHODS: Field observations were conducted in four cancer center pharmacies in four Canadian provinces from January 2013 to February 2015. Human factors specialists observed and interviewed pharmacy managers, oncology pharmacists, pharmacy technicians, and pharmacy assistants as they carried out their work. Emphasis was on latent errors (potential human failures) that could lead to outcomes such as wrong drug, dose, or diluent. RESULTS: Given the relatively short observational period, no active failures or actual errors were observed. However, 11 latent errors in chemotherapy compounding were identified. In terms of severity, all 11 errors create the potential for a patient to receive the wrong drug or dose, which in the context of cancer care, could lead to death or permanent loss of function. Three of the 11 practices were observed in our previous study, but eight were new. Applicable Canadian and international standards and guidelines do not explicitly address many of the potentially error-prone practices observed. CONCLUSION: We observed a significant degree of risk for error in manual mixing practice. These latent errors may exist in other regions where manual compounding of IV chemotherapy takes place. Continued efforts to advance standards, guidelines, technological innovation, and chemical quality testing are needed.

The effects of interruptions on oncologists' patient assessment and medication ordering practices.

Interruptions are causal factors in medication errors. Although researchers have assessed the nature and frequency of interruptions during medication administration, there has been little focus on understanding their effects during medication ordering. The goal of this research was to examine the nature, frequency, and impact of interruptions on oncologists' ordering practices. Direct observations were conducted at a Canadian cancer treatment facility to (1) document the nature, frequency, and timing of interruptions during medication ordering, and (2) quantify the use of coping mechanisms by oncologists. On average, oncologists were interrupted 17 % of their time, and were frequently interrupted during safety-critical stages of medication ordering. When confronted with interruptions, oncologists engaged/multitasked more often than resorting to deferring/blocking. While some interruptions are necessary forms of communication, efforts must be made to reduce unnecessary interruptions during safety-critical tasks, and to develop interventions that increase oncologists' resiliency to inevitable interruptions.