Advancing patient safety through structured interdisciplinary review.

445 Background: We initiated an oncology patient safety solution (PSS) committee to comprehensively review reported safety events to provide safe and high-quality care. The interdisciplinary committee reviews safety events, root cause analysis, identification of systemic and practitioner-related contributors to harm, and necessary corrective actions. This abstract describes the process and outcomes. Methods: We reviewed safety events reported through the institutional reporting system that are triaged by the Oncology Quality & Safety (Q&S) team for committee review from 2023 to 2024 based on severity, potential harm, relevance, and identified trends. The committee (comprised of physicians, nurse leaders, pharmacists, IT and operational staff) participated in comprehensive reviews. They vote on standard of care (SOC) using the Continuous Quality Improvement Classifications tool, which classifies contributing factors (system vs. practitioner), votes on harm level, and identifies any bias. The Oncology Q&S team then facilitates corrective action plans. Results: Common outcomes measures are in the table. Comparing 2023 to 2024, there was a 67% increase in the number of events reported and a 39% reduction in the average time from event to review. SOC was met for the majority of cases and most errors were attributed to practitioners. The most common intervention was counseling and education. Conclusions: The PSS committee provides a structured and collaborative approach to understanding our safety events enabling identification of system vulnerabilities and practitioner-level risks. While the number of cases presented to the committee has not increased, the efficiency of reviews improved, and the analysis of gaps and trends resulted in targeted interventions. Outcome measures from the PSS committee. Measure 2023 2024 # of events 1845 3081 # reviewed 69/4% 69/2% Average Time from event to review (days) 59 36 SOC not met 60/87% 65/94% Bias or discrimination played a role 2/3% 1/1.5% Event Categories Medication 28/46% 35/54% Laboratory 7/12% 6/10% Throughput 6/10% 8/12% Handoff/communication 5/9% 6/10% Vascular Access 5/9% - Patient Identification 4/6% 3/4% Other 4/6% 6/9% Research 1/1% 1/1% Attribution Individual practitioners 46/80% 45/69% Combined system and practitioner factors 10/17% 14/22% System-level issues 4/7% 6/9% Common Interventions Counseling and education 26/43% 39/60% New policy or workflow 19/32% 14/21% No corrective actions 5/9% - Monitoring for trends 4/7% - Other 5/9% 11/17% Audits - 1 /2%