Using 48 root cause analysis (RCA) reports drawn from 36 Department of Veterans Affairs (VA) hospitals in 28 states, researchers from Dartmouth University in Hanover, New Hampshire, determined that the most common oncology-related medical errors from October 2013 to September 2017 were due to a lack of care coordination between providers and care locations, and comprised more than half (52.1%) of all reported adverse events. Several (26.3%) of these care delays resulted in patient deaths.1
Care processes were evaluated in cases in which the oncology care team played a direct role “and those in which the provider could likely influence improvement efforts,” according to the authors.1 They asserted it was the first study of its kind to identify serious oncologic adverse events from the Veterans Health Administration National Center of Patient Safety database. Most other literature covering these types of errors are from closed claims malpractice data, they noted.
There were 83 root causes identified across the RCA reports, and they were categorized across 5 categories based on type: process or policy, communication, education or experience, staff or scheduling, and equipment or environment. The most common root causes were due to a breakdown in policy or process (39.8%) or insufficient communication (31.1%).
The second-most frequently reported adverse event was related to chemotherapy errors, and included incorrect administration of chemotherapy as well as various other problems linked to proper medication usage. Other adverse events that were identified included problems with radiation; outcomes of suicide during cancer diagnosis, treatment, or follow-up; and other events related to following care instructions.
The study authors suggested establishing dedicated cancer centers to streamline the coordination of care with multiple providers, as well as the introduction of usability testing of medical equipment by staff and standardization of processes and policies as ways to prevent adverse events.
The high occurrence of suicide observed in the study — which accounted for 10.5% of all of the oncologic adverse events and were linked to problems with care delays, patient and staff education, and communication — was a surprise to the authors, they revealed. “We suspect providers acknowledge the depression that accompanies this illness, but may not appreciate the severity of the depression or comorbid conditions, which may increase the risk of suicide.”1 Depression has been identified as a side effect of certain medications used to treat patients with cancer, and polypharmacy, in particular, may influence reports of depression.2 The authors of the current study suggested private consultations as one of the interventions that could decrease the potential for suicide in patients with malignancies.
The authors admitted that because RCA reports do not include detailed medical records for each patient, their ability to assess all factors contributing to adverse events was stunted. Nonetheless, they wrote that better communication and standardization could help close gaps in care, especially through use of a centralized model of care, barcoding or scanning the medications administered to patients, and through the increased reliance on patient navigators and nurse case managers.
- Aboumrad M, Fuld A, Soncrant C, Neily J, Paull D, Watts BV. Root cause analysis of oncology adverse events in the Veterans Health Administration [published online August 15, 2018]. J Oncol Pract. 2018;JOP1800159. doi: 10.1200/JOP.18.00159
- Qato DM, Ozenberger K, Olfson M. Prevalence of prescription medications with depression as a potential adverse effect among adults in the United States. JAMA. 2018;319(22):2289-2298. doi: 10.1001/jama.2018.6741