Nursing Practice Change Improved Chemo Administration, But Old Habits Die Hard

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Some routine aspects of chemotherapy administration may become automatic, increasing the risk for near-misses.
Some routine aspects of chemotherapy administration may become automatic, increasing the risk for near-misses.
The following article features coverage from the 2018 Oncology Nursing Society's Annual Conference in Washington, DC. Click here to read more of Oncology Nurse Advisor's conference coverage. 

WASHINGTON, DC — Nurse-identified solution to near-misses in pretreatment lab evaluations was effective in improving chemotherapy administration; however, continued efforts may be needed to sustain the practice changes, according to a presentation at the 2018 Oncology Nursing Society (ONS) Annual Congress.

Oncology nurses often find themselves multitasking in a fast-paced environment. Routine tasks such as evaluating lab results prior to administering chemotherapy may become automatic, increasing the risk for near-misses. For this project, a near-missis defined as “orders approved by nurses but halted by pharmacy.” 

Data collected over 6 nonconsecutive weeks identified a total of 36 near-misses (range, 4 to 11 near-misses/week). A nurse-led intervention was developed with the goal of reducing the number of near-misses by 50% over 3 months, explained Ayo Sato-DiLorenzo, RN, BSN, OCN, BMTCN, a nurse educator at Beth Israel Deaconess Medical Center in Boston.

For this study, the researchers created a process map to understand baseline nursing processes, a staff survey to understand existing barriers as identified by staff nurses, and a cause-and-effect diagram to categorize each existing barrier and visually present its influence on the system. 

Potential causes identified in a staff survey included lack of clear treatment criteria, delays in lab processing, and patients distressed by long wait times. Group brainstorming sessions by staff nurses produced a variety of possible interventions. Ideas were organized in priority/pay-off matrix and each evaluated for its merit based on 2 domains: perceived ease in implementation and perceived effectiveness. 

These efforts produced 2 potential interventions. A 2-nurse lab check during order verification and using the “display the last day” feature in the electronic medical record to limit lab display to the most recent results only.

Over 9 weeks, only 1 near-miss was identified. Post intervention surveillance collected 7 months after intervention initiation identified 11 near-misses over 6 weeks (range, 0 to 3 near-misses/week). Although this data demonstrated that the near-miss rate was still lower than pre-intervention rates, a slight increase had occurred since the initial implementation was noted.

A follow-up survey of the staff nurses called out the barriers to full success: a return to past habits and the primary nurse simply telling the second verifying nurse that pretreatment labs have been verified.

“Our nurse identified and led intervention was successful in reducing the number of near-misses,” concluded Sato-DiLorenzo. However, “identification of latent failures and interventions to correct them may be necessary to engender sustainable changes.”

Sato-DiLorenzo offered these 3 takeaways: choose your interventions wisely with a careful analysis of contributing factors, engage your colleagues and find solutions that are well supported, and not getting the result you were looking is your opportunity to dig in deeper.


Sato-DiLorenzo A, Wright D, Carvalho M, Coletti E, Zerillo J, Shea M. Combating chemotherapy verification fatigue: nurse-led quality improvement interventions in pre-treatment lab evaluation. Oral presentation at: ONS 43rd Annual Meeting; June 17-20, 2018; Washington, DC.

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