Congratulations to Jadine Lee-Bukovy – winner of the quarterly ‘Good Catch’ Awards.

Good Catch Awards highlight individuals, groups or departments who demonstrate their commitment to keeping patients safe by reporting a near miss. A ‘good catch’ (or near miss) is an event or situation that could have resulted in harm, but did not reach the patient because of chance or timely intervention. Reporting these events can help to identify gaps in order to prevent future adverse events from happening.

New winners will be randomly selected every quarter. Continue submitting your near misses for a chance to win! Near miss reports are submitted through the Incident Learning System (ILS). Click on the ‘safety reporting’ icon from your Novell home page, or go to the iNtranet and choose ‘Safety Reporting’ under ‘Informational’.

Jadine Lee-Bukovy, Pharmacist, was awarded a certificate and gift card to the Goods and Co. Market for her ‘near miss’ submission to the ILS. Jadine works as part of the Regional Cancer Centre pharmacy team, responsible for the delivery of IV chemotherapy in the outpatient infusion clinic. The pharmacy team works closely our oncologists and other members of the health care team to ensure patients receive optimal chemotherapy treatment at each visit. The pharmacist verifies the appropriateness of chemotherapy doses by assessing blood work for potential hematologic and organ related toxicities, by reviewing clinical assessments for chemotherapy related toxicities, and by ensuring appropriate supportive care treatments are prescribed to prevent and manage adverse effects. All IV chemotherapy medications are compounded in a controlled sterile work environment by a registered pharmacy technician under the close supervision of a pharmacist. Patient safety is a primary focus of the pharmacy team; they ensure the safe and accurate compounding and dispensing of IV chemotherapy products to our patients on a daily basis.

Details of the near miss:

• An out-patient, Mary Smith*, was assessed by a registered nurse (RN) and oncologist at her follow up appointment prior to cycle 6 liposomal doxorubicin. Chemotherapy orders were approved to be given the next day.
• During the pharmacist’s verification of chemotherapy order, she noted that the RN assessment (from the day prior) indicated that patient had some pain, peeling and redness to feet. Mary was experiencing hand/foot skin reaction, a known skin toxicity from liposomal doxorubicin. On the next day (day of treatment), the RN noted that Mary was having issues with hand/foot syndrome, indicating that these areas were red, sore, blistered and skin peeling skin to right foot.
• Although Mary had been assessed by the oncologist prior to treatment, the pharmacist intervened and requested that the RN reassess and grade the severity of hand foot syndrome, as chemotherapy treatment should be delayed by 1-2 weeks if grade 2 skin toxicity is experienced.
• After further clinical assessment of Mary and a discussion with the oncologist, treatment was held for 1 week to allow recovery of symptoms.
  
  *patient information has been changed for privacy