Background: Challenges related to access to cancer medications is an increasing global problem that has far-reaching impact on patients and healthcare systems. In this article, we are enlisting suggested solutions at the hospital or practice level to maximize the access to these important treatment modalities. Methods: An expert panel of practicing oncologists, clinical pharmacists, and health economists convened using a framework approach. The panelists identified individuals and entities that impact the use of cancer therapeutics and how they can improve the utilization and access to them. They enlisted the potential actions that hospital management and staff can take to enhance access to cancer therapeutics, then they grouped them into specific categories. Results: List of potential strategies and related action items were compiled into different categories including hospital leadership, drug evaluation entities, pharmacy, physicians, patients and families, and other parties. Recommendations included various actions to be considered by each group to achieve set goals. Conclusion: Our expert panel recommend multiple strategies and approaches to reduce the cost of cancer medications and improve patients' access to them. These recommendations can be adapted by the decision-makers and staff of the hospitals to their own settings and the current circumstances.

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Objective: Blood culture is an important laboratory test to determine bacteremia in Fungemia in patient's blood. Frequent blood culture contamination (BCC) leads to unnecessary treatment, waste of laboratory resources, and false-positive blood culture. The College of American Pathologist Accreditation states that monitoring of BCC rate should be within average 2%–3%. Based on May 2015 to May 2016 data at King Khalid University Hospital, it showed that we had experienced a consistent increase in BCC rate with an average of 4.6%. Emergency department (ED) had the highest contamination rate (5.7%). The aim of this study was to reduce the rate of contamination to <2%. Methods: A multidisciplinary quality team has been formed, (IHI) the institute for healthcare improvement model, used for improvement and other relevant quality tools for testing and implementing the choice of solution. Several plan-do-study-act (PDSA) cycles have been conducted to test the proposed solutions. All PDSA cycle data on the project measures were extracted from the lab information system to be analyzed and presented on run and control charts. Results: Over a 6-month period, a reduction in the BCC rate at the emergency department (ED) of the University Hospital reached 1.5% compared with the baseline at 4.0%. There was a significant reduction in BCC in the adult ED, which reached zero rates. However, BCC in the pediatrics ED was reduced to 1.5%, resulting from changes that were proposed, tested, and implemented during the running period. Essentially, the results of this initiative both met and exceeded the benchmark by 2%–3%. Conclusion: Standardizing work processes based on updated policy and procedures, conducting regular audits, and sending feedback are practical evidence-based strategies that lead to reducing BCC in the ED.

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Objective: To evaluate adherence of clinicians to the European guidelines for management of acute heart failure (AHF). Materials and Methods: This was a medical chart–based review study conducted from January to December 2016, including 200 medical records of patients admitted to two major hospitals in the Gaza Strip, Palestine. The AHF management was compared to the European Society of Cardiology (ESC) Guidelines, 2016. Results: The patients’ mean age was 66.0±13.0 years. A total of 100 patients (50.0%) were women and 192 (96.0%) had comorbidities including hypertension, diabetes, and heart disease. The most notable finding was that of a very poor standard of documentation, especially for vital signs. Patient management showed mostly moderate to good adherence to guidelines with 189 (94.5%) patients undergoing electrocardiogram, 90 (45.0%) echocardiography, 97 (48.5%) chest X-ray, and 79 patients of 167 (47.3%) receiving vasodilators appropriately. Good adherence was found in checking glucose levels, 176 (88.0%), and application of oxygen (100% with SpO₂ < 90%). Some aspects of care showed poor adherence, such as overuse of digoxin in 57 patients (28.5%), of which only 30 (53.4%) had atrial fibrillation and inappropriate use of beta-blockers in two patients who were hypotensive. Furthermore, brain natriuretic peptide was not used at all. Conclusion: The results of this study show suboptimal adherence to the ESC guidelines in management of AHF, reflecting the need to improve awareness of evidence-based medicine among clinicians.

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Occupational health is a sensitive area in many developing countries where occupational exposure needs attention due to lack of awareness among industrialists as well as workers. Industries such as iron, textile, leather, and paper use a vast number of toxic chemicals during different industrial processes. Workers of these industries come in direct contact with these chemicals including dyes, solvents, and finishers, which are known to be mutagenic and genotoxic. In the absence of risk assessment programs, these chemicals pose serious health risks. Risk management is one of the key factors in health safety of the workers. Agencies of central, state, and local levels need to work harder in the field of occupational health and safety. These agencies should develop relevant risk assessment programs to minimize the exposure health impacts. In the present article, various exposure risks to workers of different industries including iron, textile, leather, and paper industry along with levels of risk management system and the need for regular health assessment programs have been discussed to put them into real practice.

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Background: Although friction-reducing devices reduce the amount of force to complete a lateral transfer, the total force is significantly higher than the recommended pushing and pulling limits. Caregivers complete lateral transfers without knowing the amount of force required to laterally transfer patients, which subjects them to injury. Methods: This study was designed to identify the force to laterally transfer patients of any weight, in conditions similar to those found within the hospital of this study. There were 16 participants in this study. The participants were moved from a hospital bed to a hospital cart using two force gauges pulling two gait belts secured around the participant. Each participant was moved three times, resulting in 48 data points. A regression analysis was used to evaluate trends between two variables. A general linear model was applied and the coefficient of determination was calculated to show the percent fit to the trend line. Results: This study found a strong correlation between force of lateral transfer and the weight of the patient. Using this correlation, this study was able to predict the total force of a lateral transfer for any patient weight. The results from this study allowed for the creation of a guide to determine how many caregivers are required during a lateral transfer to maintain a safe amount of force per caregiver. Conclusion: Caregivers need to be given information regarding the forces required to complete physical movements so they can protect themselves from overexertion and injury. This study provides a guideline for caregivers to know how many people are needed to safely complete a lateral transfer.

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Background: Patient “no-shows” cause significant concern for healthcare organizations as it affects continuity of care provided to the patient, quality of care, waiting times for new patients, and wastes clinic resources. This project aimed to reduce the rate of no-shows in a general pediatric clinic to less than 10% to be consistent with the international benchmark range of 5%–10% of primary care clinics. Materials and Methods: A multidisciplinary team was formed to address the rate of no-shows using a quality improvement–driven approach in August 2017. Retrospective data analysis showed that 33% of patients who were referred to the general pediatric clinic at King Abdullah Specialist Children Hospital did not show up for their appointments in March 2017. Results: The impact of reengineering the patients’ appointment communication process led to a noticeable reduction in the rate of no-shows in the general pediatric clinic, reaching 14% in 1 month (November to December 2017) compared with the baseline of 33%. Data analysis for the post-intervention period showed a progressive decline in the no-show rate, reaching below 10% in the general pediatric clinic, indicating a big shift in the rate of no-shows among the patients attending the general pediatric clinic. Conclusion: Reengineering the communication process and increasing awareness to update contact information are effective strategies for improving communication with patients and reducing the rate of no-shows for scheduled appointments. The next step is to share project findings with healthcare workers and leaders to sustain the improvement.

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Oncology is a medical branch devoted to the study, diagnosis, treatment, and prevention of cancer. Cancer prevalence is increasing. By 2030, the global cancer burden is expected to grow to 21.7 million new cases and 13 million deaths. Developing as well as developed nations have cancer burden, but there is a gap. Ideally, cancer management involves a multidisciplinary team composed of qualified individuals from different specialties collaborating to optimize the care. This team must follow evidence-based medicine principles, considering three questions: What is the problem? How can we manage it? And why are we selecting this pathway? To fill the gaps in care, we present 10 questions that can help those who are managing patients with cancer globally. We concluded that although there is no “one-size-fits-all” approach, adhering to basic principles can help guide provision of evidence-based patient-centered care and fill some of the gaps in oncology.

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Background: The use of oral antineoplastic agents has increased in cancer medicine. However, the convenience of oral medication carries the risk of nonadherence and dosing errors, which could jeopardize therapeutic benefits and patient safety. This is a quality improvement project to investigate reasons for nonadherence and medication errors in patients receiving oral investigational treatment at the Phase 1 Department at MD Anderson Cancer Center, Houston, Texas. Early-phase clinical trials have an enormous impact on drug development and patient safety, not much has been done to evaluate adherence in patients receiving investigational oral antineoplastic agents. Materials and Methods: We examined our clinic dynamic including the initial encounter, follow-up phone calls, medication administration, and patient adherence the following visit. Then we explored and classified the main possible reasons for nonadherence and medication error across the workflow. Results: When examining potential deficiencies in the clinic flow, which are actionable and carry high impact, we found the initial encounter had a significant room for improvement and errors happened when instructions provided were unclear, not correct, or contradicted with the prescription or the label. Furthermore, the follow-up calling was also an important step to monitor and improve compliance. However, it was not a consistent practice and lacked a standardized format. Lastly and although the multistep reconciliation process for oral medication is important to monitor compliance, it was complex, had multiple manual aspects, and added substantial burden on the research staff. Conclusion: In this project, our goal was to shed light on the possible causes of oral medication errors and nonadherence in clinical trials. We proposed feasible measures including educational, training, and adherence monitoring tools. We will continue to monitor and evaluate our data to see any positive or negative impact from our interventions.

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Background: Family involvement is a critical component of patient‑centered care that impacts the quality of care and patient outcome. Our aim was to develop a patient‑ and family‑based communication model suitable for societies with extended families. Methods: A multidisciplinary team was formed to conduct a situational analysis and review the patterns of family involvement in our patient population. Patient complaints were reviewed also to identify gaps in communication with families. The team proposed a model to facilitate the involvement of the family in the patient's care through the improvement of communication. Results: A communication model was developed keeping the patient in the center of communication but involving the family through identifying the most responsible family member. To assure structured measurable contact, mandatory points of communication were defined. The model streamlines communication with the family but maintaining the patients' rights and autonomy. Conclusion: Our proposed model of communication takes into account the importance of communication with the family in a structured way. The team believes that it is going to be accepted by patients who will be explored in the pilot implementation stage as the next future step

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Background: On the basis of our patient satisfaction survey, we initiated a quality improvement project at our institution to decrease waiting times for patients scheduled for chemotherapy. The mean waiting time until a patient started his or her session was 183.5min. Our aim was to reduce the waiting time by 50% (<90min) over a 6-month period and to sustain it. Materials and Methods: We used a multidisciplinary approach to identify the root causes and contributing factors of prolonged waiting times for patients in the chemotherapy unit. We implemented three Plan–Do–Study–Act cycles over a 10-month period (February to December 2016). First, we redesigned the nursing triage process, treatment process, and nursing awareness programs. Second, we improved nursing documentation to ensure accurate tracking of patients who declined their appointment or were overbooked. Third, pharmacy forms and chemotherapy preparation were accomplished with the help of an electronic system. We implemented a department-wide standard of care to provide an early assessment of the patient on arrival, and we activated a specific chemotherapy clinic for patient booking and laboratory tests, which were supervised by a trained qualified oncologist. Results: Median time to chemotherapy administration was reduced by 40% in the first 3 months, 64% in 6 months, and 51% in 18 months. We checked every 2 weeks for sustained action and tracked the time from when the patient checked in until he or she received treatment, guided by electronic pharmacy confirmation. The mean waiting time continued to improve and no complaints were reported during the last 6 months of the post-intervention period. Conclusion: Our project resulted in a 40%–64% reduction in waiting times for patients in the chemotherapy unit over an 18-month period. Our plan is to sustain this improvement by continually monitoring waiting times and addressing any emerging issues.

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Background: Control of the quality of pharmaceutical and healthcare products in the market is mandatory to ensure the safety and efficacy of the delivered product to the final consumers. The United States Food and Drug Administration (FDA) is providing a continuous and comprehensive updated list for various healthcare issues including drug recalls. Methods: This study provides a multidimensional analysis using statistical process control (SPC) tools to evaluate the risk associated over a 3-year period (2016–2018). Results: The study showed a simple implementation of the combination of SPC tools, which demonstrated that the major contributors to recalls are microbiological quality issues, problems with product compositions, and packaging defects. Months that contributed by more than 60% of the total recalls were from May to August, November, and December. Conclusion: The general trend of drug recall rates is increasing yearly, which should be a warning signal for the regulatory agencies to take preventive measures to control and prevent excessive cases of recalls.

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Background: Family involvement is essential in providing patient-centered care. It is very challenging to adapt into the health-care system. Our project aims at implementing a culturally tailored communication model to systematically involve a family in patient care. Materials and Methods: A multidisciplinary team was established to implement our previously developed communication model. We used rapid plan–do–study–act (PDSA) cycles of improvement to test the set of interventions to incorporate learned lessons into the project activities. The communication model was implemented in stages starting from the emergency department (ED) and expanding to different hospital units. Result: Fifteen PDSA cycles were conducted in the ED, intensive care unit, and inpatient wards. A clear algorithm on how to appoint the most responsible family members was developed and points of communication with the family were identified. Educational materials were developed for patients and families in addition to staff education about the program. There was a strong acceptance of the concept from families and staff, and the process is being implemented into our electronic health records. Conclusion: Our communication model was well accepted by patients, their families, and our staff. The plan is to automate the process for sustainability by making it an integral component of the electronic medical records and to introduce it throughout our system.

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Background: During routine emergency department (ED) patient attendance validation, a trend began to emerge, related to the reason for frequent attendance among individuals. Dialogue among staff in the department who referred to this client group as “regulars” was concerning, as it was believed that it might lead to a degree of unintentional complacency that might result in a potentially vulnerable group slipping through the net. The aim was to examine the unique profile of frequent attendees, establish preventative factors, and develop action plans to offer more specific support. A multidisciplinary team was formed to examine the profiles of these cases and develop specific action plans to address their unique needs in an attempt to prevent unnecessary admissions to the ED at Cwm Taf University Health Board, South Wales. Materials and Methods: Using a Plan–Do–Study–Act methodology over 18 months, a trend analysis identified specific demographic characteristics of age and sex of the sample group (n = 11). The main reasons for attendance were related to alcohol, substance misuse, and learning disabilities. Results: Results showed that the group included eight males, five of which fell into the 18–25 age group and attended on weekdays, with peak times between 9 am and 5pm. The other three men fell into the 26–35 age group and attended most frequently after 5 pm, with the peak day being Thursdays. Weekend activity was sustained among the 18–25 age group, and the 26–35 age group had the highest attendances on Sundays. Three females from this group fell into the 26–35 age group and reflected no difference in attendance patterns. Common factors of the sample were unemployment and a socially deprived location. Conclusion: The project resulted in a 75% reduction in visits to the ED from this group of patients. Networking with other hospitals in the area yielded reports that only one of the patients had changed areas and attended another department.

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Background: Chemotherapy-induced febrile neutropenia (FN) is a major cause of morbidity and mortality in cancer patients if not treated promptly. As we were facing considerable delays in the management of chemotherapy-induced febrile neutropenic patients in the Emergency Department (ED), we initiated an improvement project aiming for “door-to-antibiotic time” of 60 minutes or less for all patients with fever and suspected chemotherapy-induced neutropenia. Methods: A multidisciplinary team was established to work on the project. We used quality improvement tools for mapping the existing patient flow processes of patients with FN in the ED. Several proposed change ideas have been tested using the Model for Improvement. These change ideas include improving the triaging process, creating an electronic “chemotherapy alert caution” and order sets for physicians, and using the hot-line by nurses to call the pharmacy to expedite the process of preparation of antibiotics. Outcome and process measures were collected weekly and they were discussed thoroughly and analyzed by the team. Run charts were used to monitor the progress. Results: After six Plan-Do-Study-Act cycles, all process measures improved and ultimately the “door-to-antibiotic time” was achieved by reducing it from 255 minutes to 49 minutes. During project testing and implementation, the nursing staff skills improvement and education were taken into consideration as a balancing measure. Conclusion: In a six-month period, the project led to a timely administration of antibiotics for patients with FN in the ED. This improvement was sustained for more than two years after the project initiation.

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Background: Analysis of rejected radiographs is an important quality indicator of any radiology department. At King Abdulaziz Medical City (KAMC), about 185,000 radiographs are performed annually. Methods: The rejected radiographs over a period of 5 years were analyzed using a dedicated electronic rejection system. The rejection is performed by a certified radiologist and communicated electronically to the concerned technologist. Results: A total of 455 rejected radiographs were reviewed and analyzed. Of the reviewed rejected radiographs, 247 were adults (60%) whereas 166 were pediatrics (40%). In terms of sex, 231 (56%) of the rejected radiographs were for men and 182 (44%) were for women. The most common reason for rejection was labeling (22%), followed by procedure protocol (20%). Other reasons included positioning (14%), processing (14%), artifacts (13%), wrong documentation (9%), and exposure error (6%). The rejection due to exposure error was very low (6%) owing to the utilization of digital systems that offer a wide exposure latitude. Reported data at hospitals that use analog systems show up to 67% of rejections were due to exposure error. In terms of body parts, the highest rejection was for extremities (43%) followed by chest (31%). The remaining rejected radiographs includes abdomen (9%), spine (8%), pelvis (5%), and head and neck (4%).Conclusion: The outcome of this study can be used to set up training programs to improve radiological services and reduce the unnecessary radiation exposure to the patients.

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Background: Hospital readmissions that occur within 30 days of the initial hospital stay are costly and potentially avoidable. Studies have shown that in addition to patients’ discharge instructions and education, follow-up calls post-discharge can significantly reduce readmission that occurs within 30 days of the initial hospital stay. Objective: To evaluate the effectiveness of nurse follow-up calls conducted in the neurosurgery service for discharged patients between October 2017 and February 2018 in reducing readmissions that occur within 30 days of initial hospital stay. Methods: An audit was initially conducted to assess compliance with conducting follow-up calls. Weekly discharge reports were used to check if patients received a follow-up call within 24–48h post-discharge. To capture the nurses’ feedback on follow-up calls, an anonymous survey was administered. Medical insurance claims data, also known as claims-based data in the American health care system, were reviewed and analyzed to assess whether there was any difference in number of days from initial discharge to readmission between patients who received a follow-up call and those who did not. Results: Results based on a multivariable regression model indicated that patients who received a follow-up call after they were discharged from initial admission stayed out of hospital longer (incidence-rate ratio = 1.54, 95% CI = [1.13, 2.10], p = 0.006) compared to those that did not receive a follow-up call. Conclusion: Readmitted patients who received post-discharge follow-up calls had significant improvements in the length of time out of the hospital. Future development could include developing additional call strategies.

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Background: Lung cancer is a public health problem in Morocco. Multiple clinical practice guidelines recommend rapid evaluation of patients with suspected lung cancer. It is uncertain whether delays in diagnosis and management are correlated with outcomes. The objective of this study was to evaluate if these delays have any negative effect on outcomes. Methods: This retrospective study included 140 patients diagnosed with non-small cell lung cancer (NSCLC). It was conducted at the Medical Oncology Department of Fez from January 2016 to December 2017. We have studied many wait times and considered that: wait time to consult (WTC) is the delay from the first symptom to initial consultation, wait time to diagnosis (WTD) is the delay from initial consultation to diagnosis, wait time to referral (WTR) is the delay from diagnosis to referral to the oncologist, and wait time to treatment (WTT) is the time from referral to treatment initiation. Our analysis used Kaplan–Meier method to estimate the overall survival (OS). To compare the OS between wait time categories, we used the logrank test. Results: The median age was 59.46 years. The sex ratio was 6 men for 1 woman. The most common histological subtype was adenocarcinoma (58.6% of cases). Eighty-two percent of patients were diagnosed at stage IV. The median WTC was 240 days (range, 15–280 days), WTD was 45 days (13–65), WTR was 54 days (13–63), and WTT was 32 days (12–40). The only factor that was associated with a long WTD was long distance (> 60 km) to the hospital (p = 0.05). We found that short WTC, WTD, and WTR had better OS: 12 versus 3 months (p < 0.0001), 12 versus 4 months (p < 0.0001), and 14 versus 5 months (p < 0.0001), respectively. We found no difference in OS between short and long WTT. Conclusion: In our study, patients with lung cancer experience significant delays from development of symptoms to first treatment initiation. We found a clear association between survival and short delays from initial symptoms to consultation, from consultation to diagnosis, and from diagnosis to referral to the department of oncology.

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Background: This study determined awareness and occupational exposures to needlestick injuries (NSIs) and its associated risk factors among healthcare workers (HCWs) in the Kumasi Metropolis, Ghana. Materials and Methods: A descriptive cross-sectional study was conducted among a total of 540 HCWs from three selected tertiary hospitals in the Kumasi Metropolis, Ghana. Data were collected using a structured questionnaire and analyzed. Results: All the study participants were aware of NSI and NSI-associated hepatitis B virus (HBV), hepatitis C virus, or human immunodeficiency virus (HIV) acquisition. Most of them (63.6%) were trained on the safety use of sharps devices and the majority of them preferred safety-engineered devices (79.8%). A greater proportion of the participants has had HBV vaccination (85.9%). The prevalence of NSIs was approximately 47%. NSIs were highly ranked to occur at patient’s bedside (28.5%) and clinical laboratories (24.6%). Handling of needles/sharp objects before usage (27.7%) and during usage (34.0%) ranked the second and first cause of NSIs among health workers, respectively. Compared with those with less than 5 years working experience, having worked at the health facility between 5 and 10 years (prevalence rate ration [PRR] = 2.07 [1.39–3.11], p = 0.0004), 11–15 years (PRR = 4.32 [2.14–8.73], p < 0.0001), and >15 years (PRR = 5.73 [2.40–13.70], p < 0.0001) were associated with increased events of NSI. Conclusion: Despite the high awareness of NSIs and its perceived risk of infection acquisition, the prevalence of NSIs was high among HCWs. There is, therefore, the need for employers to enforce the universal precaution practices, provide regular training and education, and ensure adherence of HCWs to safety precaution of needle usage disease.

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