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© The Author 2007. Published by Oxford University Press.
EDITORIALS |
Patient Safety in Cancer Care: A Time for Action
Affiliations of authors: Department of Family Medicine, University of Calgary, Calgary, AB, Canada (PGN); Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (GRB)
Correspondence to: Peter G. Norton, MD, CCFP, FCFP, Department of Family Medicine, University of Calgary, North Hill 1707, 1632-14th Ave NW, Calgary, AB T2N 1M7, Canada (e-mail: norton{at}ucalgary.ca).
Retrospective chart audit studies of acute care in several countries have shown that between 3% and 16% of patients experience one or more harmful adverse events while hospitalized and that about half of these events are preventable (1). These studies indicate that medication treatment is an area of high risk. We still know relatively little about the incidence of adverse events in nonacute settings or for specific patient populations.
In this issue of the Journal, Riechelmann et al. (2) begin to address this issue for cancer patients attending an outpatient oncology clinic. They surveyed patients concerning the medication that they had taken in the previous 4 weeks. From the information they received, they determined that 27% of the patients had the potential for one or more possibly serious drug interactions. The majority of these possible drug interactions involved not antineoplastic agents but rather drugs that were being administered for noncancer comorbidities. Although an incidence of 27% seems high, the results are consistent with what is known about the potential for adverse drug events in patients who have contact with several doctors. Indeed, Tamblyn et al. (3) concluded that "a single primary care physician and a single dispensing pharmacy may be ‘protective’ factors in preventing potentially inappropriate drug combinations." This observation has been reinforced by Blendon et al. (4), who in 2002 carried out a random survey of more than 3800 adults in the United States, Australia, Canada, New Zealand, and the United Kingdom whose health had been defined as less than optimal based on their responses to a questionnaire. More than one-third of the 66% who regularly took one or more medications had not had their medications reviewed by the physician they relied on the most for the previous 2 years. Further, 15.8% of those seeing one or two doctors reported either a medication or medical error in the last 2 years, compared with 28.8% of those seeing three or more physicians.
Many cancer patients have noncancer comorbidities and receive care from several doctors. Indeed, the study of Riechelmann et al. (2) confirms this: in their sample, the median number of comorbidities was 1, with a range of 0–5. This result is consistent with the finding of Ko and Chaudhry (5), who showed that patients with breast, prostate, lung, and colon cancers had substantial noncancer comorbidity (more than 70% had non-neoplastic cardiopulmonary diseases) and that cancer patients see more doctors and attend them more frequently than do similar patients without cancer. Ko and Chaudhry (5) stressed the need for coordination among the variety of providers who care for cancer patients and suggested that there is "a window of opportunity for specialists to help optimize even more medical comorbidities, perhaps by proper referral and coordination or by management of the disease itself."
Coordination of care for cancer patients was the theme of a recent article by Fleissig et al. (6), who reviewed the evidence for the positive effect of multidisciplinary teams in the United Kingdom and discussed the barriers to this type of care. They recommended specifically that multidisciplinary teams "liaise closely with other professionals actively involved in the support of the patient—e.g., general practitioners, other members of the primary-care team, and palliative-care specialists." We believe that such coordination and communication have the potential to substantially reduce the incidence of and mitigate possible harm from the potential drug interactions that have been discovered by Riechelmann et al. (2). In other high-risk industries, such as aviation and the offshore oil industry, many errors result from poor coordination and communication, and in these areas strategies to improve team coordination and communication have led to reductions in incidents (7,8).
Another promising approach is better use of information technology, as pointed out by the authors and demonstrated in the work of Bates et al. (9). The redesign of medication ordering, administration, and monitoring offer other opportunities for reducing adverse events. Efforts to implement routine medication reconciliation procedures at various points in the care cycle have proved successful in some areas of complex care (10). More proactive patient and family involvement in the care process also holds promise in this area. It is important to emphasize that there are no magic bullets for improving patient safety, and it is unlikely that any single strategy will provide the medication safety that is desired.
Riechelmann et al. (2) point out that their study was designed only to detect drug combinations for which there were potential risk adverse effects and that it was not possible in general to track clinical consequences. The fact that we do not know the extent of harm from these potential interactions leads to the call for further research to understand the unintentional harm experienced by cancer patients as a result of their medication treatments. The study of Riechelmann et al. (2) also suggests that to understand the burden of adverse events for cancer patients, it will be necessary to track these patients across the continuum of care and to ensure that potential adverse events are identified, reported, and investigated. Furthermore, such investigations will lead to recommendations that will require dissemination and implementation. Our knowledge of how to carry out this agenda is still nascent. The care of cancer patients could well serve as one of the platforms through which this work can move ahead.
REFERENCES
(1) Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Can Med Assoc J (2004) 170:1678–86.
(2) Riechelmann RP, Tannock IF, Wang L, Saad ED, Taback NA, Krzyzanowska MK. Potential drug interactions and duplicate prescriptions among cancer patients. J Natl Cancer Inst (2007) 99:592–600.
(3) Tamblyn RM, McLeod PJ, Abrahamowicz M, Laprise R. Do too many cooks spoil the broth? Multiple physician involvement in medical management of elderly patients and potentially inappropriate drug combinations. Can Med Assoc J (1996) 154:1177–84.[Abstract]
(4) Blendon RJ, Schoen C, DesRoches C, Osborn R, Zapert K. Common concerns amid diverse systems: health care experiences in five countries. Health Aff (Millwood) (2003) 22:106–21.
(5) Ko C, Chaudhry S. The need for a multidisciplinary approach to cancer care. J Surg Res (2002) 105:53–7.[CrossRef][Web of Science][Medline]
(6) Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol (2006) 7:935–43.[CrossRef][Web of Science][Medline]
(7) Helmreich R. On error management. Lessons from aviation. Br Med J (2000) 320:781–5.
(8) Flin RH. Crew resource management for teams in the offshore oil industry. Team Perform Manage (1997) 3:121–9.[CrossRef]
(9) Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in U.S. primary care. J Am Med Inform Assoc (2003) 10:1–10.
(10) Schwarz M, Wyskiel R. Medication reconciliation: developing and implementing a program. Crit Care Nurs Clin North Am (2006) 18:503–7.[CrossRef][Medline]
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J Natl Cancer Inst 2007 99: 592-600.
J Natl Cancer Inst 2007 99: 577.
J Natl Cancer Inst 2007 99: 577.
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