Applying ordered network analysis to video-recorded physician-nurse interactions to examine communication patterns associated with shared understanding in inpatient oncology care settings.

OBJECTIVES: The main aim of this study was to demonstrate how ordered network analysis of video-recorded interactions combined with verbal response mode (VRM) coding (eg, edification, disclosure, reflection and interpretation) can uncover specific communication patterns that contribute to the development of shared understanding between physicians and nurses. The major hypothesis was that dyads that reached shared understanding would exhibit different sequential relationships between VRM codes compared with dyads that did not reach shared understanding. DESIGN: Observational study design with the secondary analysis of video-recorded interactions. SETTING: The study was conducted on two oncology units at a large Midwestern academic health care system in the USA. PARTICIPANTS: A total of 33 unique physician-nurse dyadic interactions were included in the analysis. Participants were the physicians and nurses involved in these interactions during patient care rounds. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was the development of shared understanding between physicians and nurses, as determined by prior qualitative analysis. Secondary measures included the frequencies, orders and co-occurrences of VRM codes in the interactions. RESULTS: A Mann-Whitney U test showed that dyads that reached shared understanding (N=6) were statistically significantly different (U=148, p=0.00, r=0.93) from dyads that did not reach shared understanding (N=25) in terms of the sequential relationships between edification and disclosure, edification and advisement, as well as edification and questioning. Dyads that reached shared understanding engaged in more edification followed by disclosure, suggesting the importance of this communication pattern for reaching shared understanding. CONCLUSIONS: This novel methodology demonstrates a robust approach to inform interventions that enhance physician-nurse communication. Further research could explore applying this approach in other healthcare settings and contexts.

Oncology patients' willingness to report their medication safety concerns from home: a qualitative study.

PURPOSE: Oncology patients often struggle to manage their medications and related adverse events during transitions of care. They are expected to take an active role in self-monitoring and timely reporting of their medication safety events or concerns to clinicians. The purpose of this study was to explore the factors influencing oncology patients' willingness to report adverse events or concerns related to their medication after their transitions back home. METHODS: A qualitative interview study was conducted with adult patients with breast, prostate, lung, or colorectal cancer who experienced care transitions within the previous year. A semi-structured interview guide was developed to understand patients' perceptions of reporting mediation-related safety events or concerns from home. All interviews were conducted via phone calls, recorded, and transcribed for thematic data analysis. RESULTS: A total of 41 individuals participated in the interviews. Three main themes and six subthemes emerged, including patients' perceived relationship with clinicians (the quality of communication and trust in clinicians), perceived severity of adverse medication events (perceived severe vs. non-severe events), and patient activation in self-management (self-efficacy in self-management and engagement in monitoring health outcomes). CONCLUSION: The patient-clinician relationship significantly affects patients' reporting behaviors, which can potentially interact with other factors, including the severity of adverse events. It is important to engage oncology patients in medication safety self-reporting from home by enhancing health communication, understanding patients' perceptions of severe events, and promoting patient activation. By addressing these efforts, healthcare providers should adopt a more patient-centered approach to enhance the overall quality and safety of oncological care.

The Acceptance and Use of Digital Technologies for Self-Reporting Medication Safety Events After Care Transitions to Home in Patients With Cancer: Survey Study.

BACKGROUND: Actively engaging patients with cancer and their families in monitoring and reporting medication safety events during care transitions is indispensable for achieving optimal patient safety outcomes. However, existing patient self-reporting systems often cannot address patients' various experiences and concerns regarding medication safety over time. In addition, these systems are usually not designed for patients' just-in-time reporting. There is a significant knowledge gap in understanding the nature, scope, and causes of medication safety events after patients' transition back home because of a lack of patient engagement in self-monitoring and reporting of safety events. The challenges for patients with cancer in adopting digital technologies and engaging in self-reporting medication safety events during transitions of care have not been fully understood. OBJECTIVE: We aim to assess oncology patients' perceptions of medication and communication safety during care transitions and their willingness to use digital technologies for self-reporting medication safety events and to identify factors associated with their technology acceptance. METHODS: A cross-sectional survey study was conducted with adult patients with breast, prostate, lung, or colorectal cancer (N=204) who had experienced care transitions from hospitals or clinics to home in the past 1 year. Surveys were conducted via phone, the internet, or email between December 2021 and August 2022. Participants' perceptions of medication and communication safety and perceived usefulness, ease of use, attitude toward use, and intention to use a technology system to report their medication safety events from home were assessed as outcomes. Potential personal, clinical, and psychosocial factors were analyzed for their associations with participants' technology acceptance through bivariate correlation analyses and multiple logistic regressions. RESULTS: Participants reported strong perceptions of medication and communication safety, positively correlated with medication self-management ability and patient activation. Although most participants perceived a medication safety self-reporting system as useful (158/204, 77.5%) and easy to use (157/204, 77%), had a positive attitude toward use (162/204, 79.4%), and were willing to use such a system (129/204, 63.2%), their technology acceptance was associated with their activation levels (odds ratio [OR] 1.83, 95% CI 1.12-2.98), their perceptions of communication safety (OR 1.64, 95% CI 1.08-2.47), and whether they could receive feedback after self-reporting (OR 3.27, 95% CI 1.37-7.78). CONCLUSIONS: In general, oncology patients were willing to use digital technologies to report their medication events after care transitions back home because of their high concerns regarding medication safety. As informed and activated patients are more likely to have the knowledge and capability to initiate and engage in self-reporting, developing a patient-centered reporting system to empower patients and their families and facilitate safety health communications will help oncology patients in addressing their medication safety concerns, meeting their care needs, and holding promise to improve the quality of cancer care.

Patient symptoms, self-management, and unscheduled healthcare use during the first 6 months of targeted oral anticancer agent therapy: protocol for a mixed-methods US study.

INTRODUCTION: Targeted oral anticancer agents (OAAs) are increasingly used to treat cancer, including haematological malignancies and ovarian cancer, but they can cause serious symptomatic side effects such as arrhythmias, hypertension, and hyperglycaemia. Unaddressed OAA symptoms or inadequately managed symptoms may also lead to unnecessary and unscheduled healthcare use that decreases patient quality of life and financially burdens both patients and the healthcare system. Limited information is available about patient symptoms, self-management behaviours, and use of healthcare services over time while taking targeted OAAs, but is needed to ensure successful OAA therapy. The primary objective is to understand patient experiences and behaviours on initiating targeted OAA, and elicit cancer care clinicians' (ie, physicians, advanced practice practitioners, nurses, and pharmacists) perspectives on supporting patients during therapy. Study results will inform comprehensive and realistic interventions that minimise disruptions to therapy while maximising quality of life. METHODS AND ANALYSIS: We will conduct a remote single-arm, convergent-parallel mixed-methods cohort study within a large academic medical centre. A minimum of 60 patients will be enrolled. Patients will complete several validated patient-reported outcome measures at six timepoints over 6 months. Mixed-effects logistic regression will be used to predict the primary binary outcome of unscheduled healthcare use by patient self-efficacy for symptom self-management. Semistructured interviews will be conducted with patients and clinicians and thematically analysed. Triangulated quantitative and qualitative results will be reported using cross-case comparison joint display. ETHICS AND DISSEMINATION: This study protocol is approved by the Institutional Review Board of University of Michigan Medical School (IRBMED). Study results will be published in peer-reviewed journals, presented at conferences, and disseminated to study participants.

Photo elicitation, an approach to better understanding the patient experience with OAAs: pilot study and future implications.

PURPOSE: Oral anti-cancer agents (OAAs) represent a new frontier in cancer treatment, but we do not know how well patients incorporate the strategies that they are taught for managing the side effects of OAAs into their daily lives. The purpose of this study was to understand how OAA side effects influenced patients' lives and what strategies patients used to manage them. METHODS: The study used an interpretive descriptive design utilizing photo elicitation interviews (PEI). Two pharmacists employed at the study ambulatory oncology clinic assisted with recruitment. Participants took photos and subsequent interviews focused on talking to participants about each photo, eliciting participant perspectives describing side effects of OAAs and management strategies. A directed content analysis approach was used to analyze the transcribed interviews. RESULTS: A total of nine participants were included in the study. Three themes and associated sub-themes emerged: making changes to nutritional habits due to OAA side effects (hydration and food), strategies to alleviate OAA side effects (medication and non-medication related), and methods of coping with OAA effects (intra- and interpersonal). Changing nutritional habits was an important strategy to manage OAA side effects. Medication-related strategies to alleviate OAA side effects could be nuanced and, additionally, there was wide variability in coping methods used. CONCLUSION: Patient education on OAAs and side effects is not always tailored to each unique patient and their circumstances. This study uncovered how participants devised their own distinct strategies to prevent or manage OAA side effects in an effort to help improve patients' experiences when taking OAAs.

Development and Evaluation of a Data-Driven, Interactive Workshop to Facilitate Communication and Teamwork in Ambulatory Medical Oncology Settings.

Background: While adverse events and toxicities related to cancer drug therapy in the ambulatory oncology setting are common and often rooted in communication challenges, few studies have examined the problems of communication or tested tools to improve communication in this unique, high-risk setting. Objective: To determine the feasibility and acceptability of a virtual interdisciplinary communication Workshop designed to strengthen communication across ambulatory oncology teams members. Methods: Surveys of patients and clinicians in one ambulatory oncology clinic were analyzed and informed the communication intervention: an interdisciplinary virtual Workshop. Workshop evaluation included an implementation survey measure and a structured debrief with Workshop attendees. Results: 87 patients and 56 clinicians participated in pre-workshop surveys that revealed patient satisfaction with timely care and information, yet a range of rating communication experiences with the clinical team, and clinicians perceiving a high amount of organizational safety, yet rated discussion of alternatives to normal work processes low. Survey results guided reflection and discussion within the Workshop. Six clinicians participated in the interactive Workshop. Feasibility and acceptability of the virtual Workshop were supported by formative and summative data, along with suggestions for improvement. Conclusions: The patient and clinician surveys coupled with an interactive virtual Workshop were feasible and acceptable. Implications for Practice: The Workshop identified opportunities for individual- and system-level improvements in clinical team communication. This promising strategy requires replication in larger, diverse practice samples. Foundational: Clinicians accepted an interactive workshop that incorporated clinic-specific data and communication strategies. The program is feasible and acceptable in ambulatory oncology settings.

Video reflexive ethnography as an intervention to improve oral anti-cancer agent patient education: A pilot study.

Objective: Oral anticancer agents (OAAs) are associated with side effects that interfere with medication adherence, despite patient education regarding side effect management. Video reflexive ethnography (VRE) captures care processes on video that allow participants to learn from videos. The purpose of this pilot study was to assess the usefulness and impact of VRE on improving OAA education. Methods: This qualitative study was conducted in a pharmacist-managed OAA clinic: two pharmacists and four patients participated. We filmed each pharmacist providing education to two patients. We conducted patient interviews and one reflexivity session with both pharmacists to learn participants' perspectives. We used thematic content analysis to analyze data. Results: Two themes emerged: what patients liked/helped, and things that were unclear. Patients liked instructions on temperature taking, directions to safely handle and store OAAs. Unclear areas included knowing the timing of the worst side effects.During the reflexivity session, pharmacists found patients' comments useful to improve their practice. Conclusion: VRE was acceptable to pharmacists and patients. Pharmacists recognized VRE as a helpful technique to improve patient education on OAAs. Innovation: The use of video enables participants to scrutinize and reshape their practices, making VRE a powerful innovation and adjunct to quality improvement initiatives.

Temporally guided articulated hand pose tracking in surgical videos.

PURPOSE: Articulated hand pose tracking is an under-explored problem that carries the potential for use in an extensive number of applications, especially in the medical domain. With a robust and accurate tracking system on surgical videos, the motion dynamics and movement patterns of the hands can be captured and analyzed for many rich tasks. METHODS: In this work, we propose a novel hand pose estimation model, CondPose, which improves detection and tracking accuracy by incorporating a pose prior into its prediction. We show improvements over state-of-the-art methods which provide frame-wise independent predictions, by following a temporally guided approach that effectively leverages past predictions. RESULTS: We collect Surgical Hands, the first dataset that provides multi-instance articulated hand pose annotations for videos. Our dataset provides over 8.1k annotated hand poses from publicly available surgical videos and bounding boxes, pose annotations, and tracking IDs to enable multi-instance tracking. When evaluated on Surgical Hands, we show our method outperforms the state-of-the-art approach using mean Average Precision, to measure pose estimation accuracy, and Multiple Object Tracking Accuracy, to assess pose tracking performance. CONCLUSION: In comparison to a frame-wise independent strategy, we show greater performance in detecting and tracking hand poses and more substantial impact on localization accuracy. This has positive implications in generating more accurate representations of hands in the scene to be used for targeted downstream tasks.

Which Factors Promote Shared Understanding Between Physicians and Nurses in Inpatient Oncology Care Settings?: A Qualitative Exploration.

BACKGROUND: Effective communication between physicians and nurses is crucial to the safety of patients, especially for those with cancer, which is a complex disease requiring multidisciplinary treatment. However, little is known about the factors that contribute to effective communication, which is defined as the development of shared understanding between two or more people. OBJECTIVE: This qualitative secondary analysis was conducted to identify factors that contribute to shared understanding between physicians and nurses from video-recorded conversations that occurred between them during inpatient rounds on oncology units. METHODS: We used inductive grounded theory to identify videos depicting moments of shared understanding. We then searched for preceding events to develop a preliminary conceptual model that described the factors contributing to shared understanding. RESULTS: Four factors emerged as contributors to shared understanding: engagement, clarification, confirmation, and resolution. These factors occurred in sequence with engagement occurring first and resolution occurring last, as the closure of a communication exchange. CONCLUSIONS: Existing interventions to improve communication include some of the factors identified as contributing to shared understanding (eg, closed-loop communications require clarification and confirmation). However, nurses may need to pay attention to all four factors to develop shared understanding that will promote effective communication with physicians and thereby enhance cancer care. IMPLICATIONS FOR PRACTICE: Nurses achieve effective communication when they are assertive and avoid indirect communication. A greater awareness of body language and positioning in relation to a physician at the start of a communication exchange may increase the effectiveness of nurse-physician communication.

Interventions for the Prevention of Retained Surgical Items: A Systematic Review.

BACKGROUND: Retained surgical items (RSI) are preventable error events. Interest in reducing RSI is increasing globally because of increasing demand for safe surgery. While research of interventions to prevent RSI have been reported, no rigorous analysis of the type and effectiveness of interventions exists. This systematic review examines (1) what types of intervention have been implemented to prevent RSI; and (2) what is the effectiveness of those interventions. METHODS: We performed a systematic review of PubMed, Embase, CINAHL, Cochrane Library, Scopus, ClinicalTrials.gov, Mednar, and OpenGrey databases. Two reviewers independently screened a total of 1,792 titles and abstracts, and reviewed 87 full-text articles, resulting in 17 articles in the final analysis. Study characteristics included qualitative and quantitative studies that examined the effectiveness of RSI prevention interventions for adult patients who undergo open surgery. The primary outcome was RSI and related error events. RESULTS: Four studies and 13 quality improvement projects described RSI interventions categorized into four groups: (1) technology-based, (2) communication-based, (3) practice- or guideline-based, (4) interventions that fell into more than one category. Following guidance in the Quality Improvement minimum quality criteria set, the quality of all studies ranged from poor to fair. Heterogeneity in the interventions used and variable study quality limit our confidence in the interventions' ability to reduce RSI. CONCLUSION: Since technology-based interventions may not be financially feasible in low and middle-income countries (LMIC), in those settings interventions that target the social system may be more appropriate. Rigorous methods to investigate local contexts and build knowledge are needed so that interventions to prevent RSI have a greater likelihood of success.

Influences of Physical Layout and Space on Patient Safety and Communication in Ambulatory Oncology Practices: A Multisite, Mixed Method Investigation.

OBJECTIVE: To examine how physical layouts and space in ambulatory oncology practices influence patient safety and clinician communication. BACKGROUND: Ambulatory oncology practices face unique challenges in delivering safe care. With increasing patient volumes, these settings require additional attention to support patient safety and efficient clinical work processes. METHODS: This study used a mixed methods design with sequential data collection. Eight ambulatory oncology practices (of 29 participating practices) participated in both the quantitative and qualitative phases. In surveys, clinicians (n = 56) reported on safety organizing and communication satisfaction measures. Qualitative data included observations and semistructured interviews (n = 46) with insight into how physical layout influenced care delivery. Quantitative analysis of survey data included descriptive and correlational statistics. Qualitative analysis used inductive and thematic content analysis. Quantitative and qualitative data were integrated using side-by-side comparison tables for thematic analysis. RESULTS: Safety organizing performance was positively correlated with clinician communication satisfaction, r(54 df) = .414, p = .002. Qualitative analyses affirmed that the physical layout affected communication around chemotherapy infusion and ultimately patient safety. After data integration, safety organizing and clinician communication were represented by two themes: visibility of patients during infusion and the proximity of clinicians in the infusion center to clinicians in the clinic where providers see patients. CONCLUSIONS: Physical layouts of ambulatory oncology practices are an important factor to promote patient safety. Our findings inform efforts to construct new and modify existing infusion centers to enhance patient safety and clinician communication.

The impact of team familiarity on intra and postoperative cardiac surgical outcomes.

BACKGROUND: Familiarity among cardiac surgery team members may be an important contributor to better outcomes and thus serve as a target for enhancing outcomes. METHODS: Adult cardiac surgical procedures (n = 4,445) involving intraoperative providers were evaluated at a tertiary hospital between 2016 and 2020. Team familiarity (mean of prior cardiac surgeries performed by participating surgeon/nonsurgeon pairs within 2 years before the operation) were regressed on cardiopulmonary bypass duration (primary-an intraoperative measure of care efficiency) and postoperative complication outcomes (major morbidity, mortality), adjusting for provider experience, surgeon 2-year case volume before the surgery, case start time, weekday, and perioperative risk factors. The relationship between team familiarity and outcomes was assessed across predicted risk strata. RESULTS: Median (interquartile range) cardiopulmonary bypass duration was 132 (91-192) minutes, and 698 (15.7%) patients developed major postoperative morbidity. The relationship between team familiarity and cardiopulmonary bypass duration significantly differed across predicted risk strata (P = .0001). High (relative to low) team familiarity was associated with reduced cardiopulmonary bypass duration for medium-risk (-24 minutes) and high-risk (-27 minutes) patients. Increasing team familiarity was not significantly associated with the odds of major morbidity and mortality. CONCLUSION: Team familiarity, which was predictive of improved intraoperative efficiency without compromising major postoperative outcomes, may serve as a novel quality improvement target in the setting of cardiac surgery.

Factors Associated With Job Satisfaction in Medical Oncology Practices: Results From a Multisite Survey.

OBJECTIVE: The aim of this study was to examine the factors influencing job satisfaction of nurses, physicians, and advanced practice providers in ambulatory oncology settings. BACKGROUND: Job satisfaction is essential to clinician well-being and quality of care. METHODS: In 2017, clinicians from 29 ambulatory medical oncology practices completed anonymous paper questionnaires that examined job satisfaction, clinician-to-clinician communication, and perceptions of patient safety. Linear regression, adjusted for clustered observations, examined the relationship between job satisfaction, clinician communication, and patient safety perceptions. RESULTS: Of 280 respondents (response rate of 68%), 85% reported that they were satisfied or very satisfied with their current position. Patient safety and accuracy of clinician communication were positively and significantly associated with job satisfaction. CONCLUSIONS: Although most surveyed clinicians were satisfied, 15% were dissatisfied and reported communication and safety concerns. Leadership efforts to strengthen clinician communication actions and develop positive safety cultures are promising strategies to promote clinician well-being and high-quality cancer care.

Novel Assessments of Technical and Nontechnical Cardiac Surgery Quality: Protocol for a Mixed Methods Study.

BACKGROUND: Of the 150,000 patients annually undergoing coronary artery bypass grafting, 35% develop complications that increase mortality 5 fold and expenditure by 50%. Differences in patient risk and operative approach explain only 2% of hospital variations in some complications. The intraoperative phase remains understudied as a source of variation, despite its complexity and amenability to improvement. OBJECTIVE: The objectives of this study are to (1) investigate the relationship between peer assessments of intraoperative technical skills and nontechnical practices with risk-adjusted complication rates and (2) evaluate the feasibility of using computer-based metrics to automate the assessment of important intraoperative technical skills and nontechnical practices. METHODS: This multicenter study will use video recording, established peer assessment tools, electronic health record data, registry data, and a high-dimensional computer vision approach to (1) investigate the relationship between peer assessments of surgeon technical skills and variability in risk-adjusted patient adverse events; (2) investigate the relationship between peer assessments of intraoperative team-based nontechnical practices and variability in risk-adjusted patient adverse events; and (3) use quantitative and qualitative methods to explore the feasibility of using objective, data-driven, computer-based assessments to automate the measurement of important intraoperative determinants of risk-adjusted patient adverse events. RESULTS: The project has been funded by the National Heart, Lung and Blood Institute in 2019 (R01HL146619). Preliminary Institutional Review Board review has been completed at the University of Michigan by the Institutional Review Boards of the University of Michigan Medical School. CONCLUSIONS: We anticipate that this project will substantially increase our ability to assess determinants of variation in complication rates by specifically studying a surgeon's technical skills and operating room team member nontechnical practices. These findings may provide effective targets for future trials or quality improvement initiatives to enhance the quality and safety of cardiac surgical patient care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/22536.

Clinicians Report Barriers and Facilitators to High-Quality Ambulatory Oncology Care.

BACKGROUND: Ambulatory oncology practices treat thousands of Americans on a daily basis with high-risk and high-cost antineoplastic agents. However, we know relatively little about these diverse practices and the organizational structures influencing care delivery. OBJECTIVE: The aim of this study was to examine clinician-reported factors within ambulatory oncology practices that affect care delivery processes and outcomes for patients and clinicians. METHODS: Survey data were collected in 2017 from 298 clinicians (nurses, physicians, nurse practitioners, and physician assistants) across 29 ambulatory practices in Michigan. Clinicians provided written comments about favorable and unfavorable aspects of their work environments that affected their ability to deliver high-quality care. We conducted inductive content analysis and used the Systems Engineering Initiative for Patient Safety work system model to organize and explain our findings. RESULTS: Clinicians reported factors within all 5 work-system components of the Systems Engineering Initiative for Patient Safety model that affected care delivery and outcomes. Common themes surfaced, such as unfavorable aspects including staffing inadequacy and high patient volume, limited physical space, electronic health record usability issues, and order entry. Frequent favorable aspects focused on the skills of colleagues, collaboration, and teamwork. Some clinicians explicitly reported how work system factors were relational and influenced patient, clinician, and organizational outcomes. CONCLUSIONS: These findings show how work-system components are interactive and relational reflecting the complex nature of care delivery. IMPLICATIONS FOR NURSING PRACTICE: Data obtained from frontline clinicians can support leaders in making organizational changes that are congruent with clinician observations of practices' strengths and opportunities for improvement.

Patient-reported outcomes collected in ambulatory oncology practices: Feasibility, patterns, and correlates.

OBJECTIVE: To examine the feasibility of soliciting outcomes from adults who received chemotherapy treatment for cancer and describe the patterns and correlates of patient-reported toxicities. DATA SOURCES: Patient survey data from 29 Michigan ambulatory oncology practices collected in 2017. STUDY DESIGN: Secondary analysis of patient survey data. Descriptive statistics were generated at the patient and practice levels. Thematic analysis of open-text comments identified clusters of frequently reported toxicities. DATA COLLECTION METHODS: Patients completed 11 items from the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events. Using a 5-point Likert scale, patients rated the frequency of nausea, vomiting, diarrhea, and pain; the severity of nausea, vomiting, constipation, numbness/tingling, and pain; and how much numbness/tingling and pain interfered with usual or daily activities. Patients could also report two toxicities in open-text comments. Finally, patients reported unplanned health care service for toxicity or side effect management. PRINCIPAL FINDINGS: Of 3565 eligible patients, 2245 participated (63%) and 457 (20%) rated at least one toxicity as severe/very severe. Across practices, the proportion of patients who reported at least one severe/very severe toxicity ranged from 8% to 50%. Troubling toxicities included pain frequency (mean 2.3, SD 1.3), pain severity (2.1, 1.1), and diarrhea frequency (1.9, 1.0). From completed assessments, 1653 (74%) reported at least one toxicity in open-text comments; fatigue (n = 182), stomach discomfort (n = 53), and skin/nail changes (n = 41) were most frequently reported. Regarding consequences, 156 patients (7%) reported unplanned health care service use: 41 (26%) visited an emergency department and 32 (21%) were admitted to a hospital. CONCLUSIONS: Querying patients on chemotherapy treatment experiences and toxicities was feasible. Toxicity rates varied across practices, which informed quality improvement. Toxicity severity and service use incidence exceed previously published trial data, particularly for pain, fatigue, and gastrointestinal issues. Open-text questions enabled exploration with newer treatment regimens.

Causes and Consequences of Chemotherapy Delays in Ambulatory Oncology Practices: A Multisite Qualitative Study.

PURPOSE: In oncology, chemotherapy treatment delays potentially jeopardize patient safety and impede progress toward disease remission. The purpose of this study was to examine the causes and consequences of chemotherapy treatment delays and possible solutions to improve quality of care. PARTICIPANTS & SETTING: The current authors selected a purposive sample of eight ambulatory oncology practices for ethnographic site visits, which lasted five days each. METHODOLOGIC APPROACH: The authors conducted 290 observation hours, including clinician shadowing, and 46 semistructured interviews with clinicians (oncology nurses, physicians, and advanced practice providers). Deductive and inductive thematic analysis was performed on all data. FINDINGS: The authors identified four primary themes from the analysis that affect delays. IMPLICATIONS FOR NURSING: Future investigations should examine nurses' communication practices in the context of timely chemotherapy administration because communication and documentation technologies within healthcare settings continuously evolve.

Facilitators and Barriers to Recruiting Ambulatory Oncology Practices Into a Large Multisite Study: Mixed Methods Study.

BACKGROUND: Practice-based research is essential to generate the data necessary to understand outcomes in ambulatory oncology care. Although there is an increased interest in studying ambulatory oncology care, given the rising patient volumes and complexity in those settings, little guidance is available on how best to recruit ambulatory oncology practices for research. OBJECTIVE: This paper aimed to describe the facilitators and barriers to recruiting ambulatory oncology practices into a large multisite study. METHODS: Using a mixed methods design, we sought to recruit 52 ambulatory oncology practices that have participated in a state-wide quality improvement collaborative for the quantitative phase. We used 4 domains of the Consolidated Framework for Implementation Research (CFIR) to describe facilitators and barriers to recruitment. RESULTS: We successfully recruited 28 of the 52 collaborative-affiliated practices, collecting survey data from 2223 patients and 297 clinicians. Intervention attributes included multimodal outreach and training activities to assure high fidelity to the data collection protocol. The implementation process was enhanced through interactive training and practice-assigned champions responsible for data collection. External context attributes that facilitated practice recruitment included partnership with a quality improvement collaborative and the inclusion of a staff member from the collaborative in our team. Key opinion leaders within each practice who could identify challenges to participation and propose flexible solutions represented internal context attributes. We also reported lessons learned during the recruitment process, which included navigating diverse approaches to human subjects protection policies and understanding that recruitment could be a negotiated process that took longer than anticipated, among others. CONCLUSIONS: Our experience provides other researchers with challenges to anticipate and possible solutions for common issues. Using the CFIR as a guide, we identified numerous recruitment barriers and facilitators and devised strategies to enhance recruitment efforts. In conclusion, researchers and clinicians can partner effectively to design and implement research protocols that ultimately benefit patients who are increasingly seeking care in ambulatory practices.

Using Incident Reports to Assess Communication Failures and Patient Outcomes.

INTRODUCTION: Communication failures pose a significant threat to the quality of care and safety of hospitalized patients. Yet little is known about the nature of communication failures. The aims of this study were to identify and describe types of communication failures in which nurses and physicians were involved and determine how different types of communication failures might affect patient outcomes. METHODS: Incident reports filed during fiscal year 2015-2016 at a Midwestern academic health care system (N = 16,165) were electronically filtered and manually reviewed to identify reports that described communication failures involving nurses and physicians (n = 161). Failures were categorized by type using two classification systems: contextual and conceptual. Thematic analysis was used to identify patient outcomes: actual or potential harm, patient dissatisfaction, delay in care, or no harm. Frequency of failure types and outcomes were assessed using descriptive statistics. Associations between failure type and patient outcomes were evaluated using Fisher's exact test. RESULTS: Of the 211 identified contextual communication failures, errors of omission were the most common (27.0%). More than half of conceptual failures were transfer of information failures (58.4%), while 41.6% demonstrated a lack of shared understanding. Of the 179 identified outcomes, 38.0% were delays in care, 20.1% were physical harm, and 8.9% were dissatisfaction. There was no statistically significant association between failure type category and patient outcomes. CONCLUSION: It was found that incident reports could identify specific types of communication failures and patient outcomes. This work provides a basis for future intervention development to prevent communication-related adverse events by tailoring interventions to specific types of failures.

Clinician Perspectives on Electronic Health Records, Communication, and Patient Safety Across Diverse Medical Oncology Practices.

PURPOSE: We know little about how increased technological sophistication of clinical practices affects safety of chemotherapy delivery in the outpatient setting. This study investigated to what degree electronic health records (EHRs), satisfaction with technology, and quality of clinician-to-clinician communication enable a safety culture. METHODS: We measured actions consistent with a safety culture, satisfaction with practice technology, and quality of clinician communication using validated instruments among 297 oncology nurses and prescribers in a statewide collaborative. We constructed an index to reflect practice reliance on EHRs (1 = "all paper" to 5 = "all electronic"). Linear regression models (with robust SEs to account for clustering) examined relationships between independent variables of interest and safety. Models were adjusted for clinician age. RESULTS: The survey response rate was 68% (76% for nurses and 59% for prescribers). The mean (standard deviation) safety score was 5.3 (1.1), with a practice-level range of 4.9 to 5.4. Prescribers reported fewer safety actions than nurses. Higher satisfaction with technology and higher-quality clinician communication were significantly associated with increased safety actions, whereas increased reliance on EHRs was significantly associated with lower safety actions. CONCLUSION: Practices vary in their performance of patient safety actions. Supporting clinicians to integrate technology and strengthen communication are promising intervention targets. The inverse relationship between reliance on EHRs and safety suggests that technology may not facilitate clinicians' ability to attend to patient safety. Efforts to improve cancer care quality should focus on more seamless integration of EHRs into routine care delivery and emphasize increasing the capacity of all care clinicians to communicate effectively and coordinate efforts when administering high-risk treatments in ambulatory settings.