Kara Browne - ISOPP 2014 Summary Report

I had the opportunity to attend ISOPP 2014 in Montreal, in part from a travel grant awarded to me by CAPhO, and support from my employer.  The theme of ISOPP 2014 was, “Building Partnerships in Care”.  This theme was evident throughout the symposium with presentations by pharmacists, physicians, cancer survivors and human factor specialists.
There was a large focus on safety and human factors.  There were multiple case presentations on errors that occurred at different sites.  All had a common theme of human factor error and system failure, with the overall message that errors are not a cause of an unsafe system, but rather a consequence of.
Some of the contributing factors to these errors are things that we as oncology pharmacy personnel deal with on a daily basis, and if we don’t strive to eliminate them from our process, we could one day be telling the story of our error.
Contributing Factors:
  • Delayed labels
  • New staff
  • Not following normal protocol
  • Not checking all vials used for a preparation
  • Unnecessary time pressures
  • Overcrowding of checking area
  • Different systems in place
  • Confirmation bias
Too often, we employ a “CDB” attitude – “Can’t Do Because”.  When a change is proposed, it’s easy to say that our current process is working just fine, and that there’s no need to change. In these situations, we need to ask ourselves “Is there any reason to not implement this change? If an error occurred under the current system, would you be able to defend your choice to not implement the change?” I found this way of looking at it so powerful and I think it’s a great way to frame our evaluation of new ideas.  We also need to consider the idea of omission bias - we tend to judge harmful actions as worse than equally harmful inactions.
Other human factors that lead to errors occurring are themes such as “groupthink” - we all assume that with so many hands in the pot that someone will always catch what we may not.  It gives us an illusion of invulnerability, creates excessive optimism and encourages risk-taking.  When we are doing the same task over and over again, over time there is a risk of a posterior probability error: the tendency to believe that an outcome will be like those that preceded it.
Most errors don’t come from a single action, but rather a constant and slow degradation of the safety system over time.  The same can be said about making our work safer for our patients and ourselves.  There is no one giant step that does it all.  It’s a lot of little steps and there is no endpoint.  It’s a constant state of improvement and we can never be satisfied with our processes.  
I returned from ISOPP with new framework with which to evaluate processes and systems within my own department and with a new level of enthusiasm towards patient safety.  I’ve been able to identify a few safety initiatives which can be easily implemented within my own department that will hopefully improve our safety process. Being able to meet with other oncology professionals from around the world is so beneficial.  We can all learn from each other.  When we share our knowledge from our experiences, good and bad, we strengthen the foundation of oncology pharmacy safety.
Kara Browne
Oncology Pharmacy Technician, Saskatoon Cancer Centre