Cancer’s a

risky business:
risk assessment in
oncology nursing.
Janice Richmond,
RN, RANP, RNP, BSc (Hons), PGDip, DNSc, FFNMRSCI

Advanced Nurse Practitioner Oncology,

Letterkenny University Hospital, Co Donegal, Ireland
 Disclosure

No conflict of interest
 Overview
➢ Introduction and definition
➢ Literature review
➢ Clinical understanding of risk assessment
➢ Risk assessment tools in cancer care
➢ Scope and limitation of tools
➢ Conclusion
 Introduction
and definition
Patient safety

Maintaining a safe
environment

(Roper et a1, 1980)

 Definitions
of risk assessment
Definitions
Hazards can cause
harm. Risk is the
chance that a hazard
will cause harm. Risk
assessment is the
process of working
out the likelihood of
hazards causing harm
Literature review
“As expected there
were 1,000s of
results”
 So....risk in health care
exists....but maybe patients
don’t know this..........?
 Patients’ perception of risk
416 patients approached-93 actually believed
something had gone wrong in their care that was
preventable.

In-depth telephone interviews (n=78)

➢ 28%-problem with medical care gone wrong
➢ 47%-problem with communication
➢ 24%-problem with medical care and
communication
(Mazer et al, 2012)
 Patients’ perception of risk
Preventing errors in “I was exposed to
oncology: a several hazardous
physician’s situations because of
perspective as cancer nurses’ errors”
of the neck patient
Itzhak Brook (2016) “Miraculously these
incidents did not
cause long-term
harm”
 Hazards and harm
and risk definitely exist

Hannisdal et al (2013)
➢ 16 hazards identified

➢ Follow up study
 4 new hazards identified
 Department established goals for 3 of them
Clinical understanding
of risk/risk assessment
• Waterlow risk assessment for pressure sore prevention
• Falls risk assessment
• Malnutrition Screening tool
•Medication Interaction tools
•Bed rail risk assessment
•Montreal cognitive Assessment (MOCA) to assess
cognition pre SACT
 Clinical understanding
Colleagues (Clinical nurses)

➢ “Alot of what we do is risk assessment but we don’t

frame it as such……and has implications for training”
➢ Infection control
➢ Telephone triage of unwell patient
➢ Triage pre-chemo-overall health/situation of patient
➢ Assessment for extravasation/need for central line
➢ Chemo spillage/equipment
➢ Safety in drug checking/administration
➢ Patients understanding of situation/treatments
 Clinical understanding
Colleagues (Clinical nurses)

➢ Clinical Trials nurse

 Family history
 Genetics
 Risk of secondary malignancy

➢ Out-patient nurses
 Falls
 Moving and handling
 Infection control
 Clinical understanding
Managers
➢ Drug administration
➢ Skill set of staff involved
➢ Competency
➢ Environmental issues

ANPs in Ireland (via email)

➢ Objective assessment tools
➢ Holistic/all encompassing assessment to determine
patient/family understanding of situation/treatments
➢ Structured professional judgement
Risk assessment tools
in cancer care
 Tools
Febrile neutropenia-is life threatening and
international evidence based guidelines
recommends prophylactic G-CSF for patients at
risk of developing such.

 Largely inconsistent prescribing

 Driven by medical choice/experience
(O’Brien et al, 2014)
 Tools
Febrile neutropenia risk assessment tool

➢ FN was reduced by 52% (p = 0.02)

➢ Significant reduction in life-threatening

infections, hospitalisations, dose reductions and
delays
(O’Brien et al, 2014)
 Tools
24 hour triage rapid
assessment and
tool kit.

United Kingdom
Oncology Nursing
Society (2016)
 Tools
UKONS telephone RED- any toxicities graded
here take priority and
triage tool (UKONS) assessment should follow
immediately as face-to-face
consultation

AMBER-Two or more amber

toxicities should be escalated
to red action and assessment
should follow. 1 Amber
review/call back in 24 hours

Green callers should be

instructed to call back if they
continue to have concerns or
their condition deteriorates.
 Tools
Drug interaction assessment tools

➢ Lexicomp
➢ Micromedex
➢ Stockleys
 Tools
➢ Chemotherapy Risk Assessment Scale for High-Age
Patients (CRASH) (Extermann et al, 2012)
➢ Multidisciplinary risk assessments
 1 day evaluation to include cardiologist, geriatrician,
diabetologist, anesthetist, pharmacist, pain specialist,
dietician, psychologist and social worker.
 N=87 (mean age 81)

“A one-day multidisciplinary risk assessment…..improves the

safety of SACT.”
Huillard et al (2014)
 Tools
Pregnancy Risk Assessment
➢ A patient's reproductive goals and risk factors
for pregnancy are inconsistently addressed
during initial consultation with the gynecologic
oncologist.
➢ Increases risk for unplanned pregnancy
➢ Results in a missed opportunity for fertility
preservation.
(Crafton et al, 2016)
Scope and limitations of risk
assessment
 Scope and limitations
32 common errors in risk assessment

Organisation

Equipment
Product HUMAN

Environment
 Scope and limitations
Need to be actually performed-for example…..

Falls risk assessment reduce falls (Cabilan, 2014;

Towsend et al, 2016).

“There was an accuracy in fall risk assessments,

and therefore..........if performed............falls
prevention... would improve”
(Cabilan, 2014)
 Scope and limitations
➢ Lack of consistency among VTE tools
(Stroud et al, 2014; Bell et al, 2015;
Lukaszuk et al, 2018)
➢ Never specific enough for subspecialties
or high risk groups (Barber & Clarke-
Pearson 2016)
➢ Further clinical validation of tools required
➢ Time consuming (eg 1 day CRASH model)
 Scope and limitations
Drug interactions:

➢ Over-reported

➢ Exaggerated risk
 Assessment of risk
Autonomic system Reflective system
➢ Uncontrolled ➢ Controlled
➢ Effortless ➢ Effortful
➢ Associative ➢ Deductive
➢ Fast ➢ Slower
➢ Unconscious ➢ Self-aware
➢ Skilled ➢ Rule following

Thaler & Sunstein (2008)

 Assessment of risk

Professional and structured

judgement assessment

Richmond & Wright (2002) Lannering et al (2016)

Abayomi & Hackett (2004) Petrucci (2014)
 Scope and limitations
Leads to a change in practice:
➢ Pressure ulcer risk assessments
➢ Drug interaction assessment tools standard of
care
➢ Thromboprophylaxis in hospitalized medical
oncology patients (Ay & Pabinger, 2015)
➢ Neutropenia assessment tool (O’Brien et al,
2014) -cost effective outcomes (Ropka et al,
2005)
➢ Constantly evolving (Ropka et al, 2005).
Conclusion
 Conclusions
Risk in health care exists with potential to
cause harm
Organisation

Equipment
Product STAFF

Environment
 Talk
about
the risks
Analyse/
Analyse
compare
the risk
the tools

Training Document
risk (risk
register)

Develop risk
assessment
tools
Conclusions
References
 References

➢ Abayomi, J., Hackett, Al. (2004) Assessment of malnutrition in mental health clients:
nurses' judgement vs. a nutrition risk tool. Journal of Advanced Nursing. 45(4):430-437.
➢ Ay C., Pabinger I. (2015) VTE risk assessment in cancer. Who needs prophylaxis and
who does not. Hamostaseologie. 35(4):319-24.
➢ Barber, E. L., Clarke-Pearson, D. L (2016) The limited utility of currently available
venous thromboembolism risk assessment tools in gynecological oncology patients.
American Journal of Obstetrics & Gynecology. 215(4):445e1-445e9,
➢ Bell, A.D., Hockenberry, M., Landier, W., Ewing, N., (2015) Venous Thromboembolism
Risk Assessment and Prophylaxis Use in Pediatric, Adolescent, and Young Adult
Hematology Oncology Patients. Journal of Pediatric Hematology/Oncology.
37(6):455-458.
➢ Bennett, C.L., Calhoun, E.A. (2007) Evaluating the total costs of chemotherapy induced
febrile neutropenia: results from a pilot study with community oncology cancer patients.
Oncologist 12 (4), 478e483.
➢ Bird, F. E.,Germain, G. L. (1996) Practical Loss Control Leadership. International Loss
Control Leadership.
 References

➢ Blazer, K., Christie, C., Uman, G., Weitzel, J., Blazer, K.R., Weitzel, J. N. (2012)
Impact of web-based case conferencing on cancer genetics training outcomes for
community-based clinicians. Journal of Cancer Education, 2012; 27(2): 217-225.
➢ Brook, I. (2016) Preventing errors in Oncology: a physician’s perspective as cancer of
the neck patient. Rambam Maimonides Medical Journal,7 (3).
➢ Cabilan, C. J. (2014) Falls risk assessment and falls prevention strategies in private
oncology and neurosurgical setting: a best practice implementation project.. JBI
Database of Systematic Reviews and Implementation Reports. 12(10):218-233.
➢ Cohen S.A., Nixon D.M. (2016) A collaborative approach to cancer risk assessment
services using genetic counselor extenders in a multi-system
community hospital. Cancer Research & Treatment. 159(3):527-34
➢ Coulahan, P (2009) Sports Clubs Risk Assessment Guidelines. Unpublished work
➢ Crafton, S., Nekkanti, S., Lynch, C., Cohn, D. E., Fowler, J. M. Copeland, L.J.,
O'Malley, D.M. , Salani, R., Backes, Fl.J., Eisenhauer, E,L. (2016) Documentation of
Pregnancy Risk Assessment and Pregnancy Among Women Presenting for
Gynecologic Oncology Consultation. International Journal of Gynecological Cancer.
26(1):35-42.
 References

➢ Curtis, R (2015) Risk Assessment & Safety Management Model (RASM) © . Princeton
University Outdoor Action Program
➢ European Agency for Safety and Health at Work. 32 common errors in the risk
assessment process. http://osha.europa.eu
➢ Extermann, M., Boler, I., Reich, R.R., Lyman, G H., Brown, R. H., DeFelice, J.,
Levine, R. M., Lubiner, E.T., Reyes, P., Schreiber, F.J., Balducci, L. (2012) Predicting
the risk of chemotherapy toxicity in older patients: The Chemotherapy Risk Assessment
Scale for High-Age Patients (CRASH) score. Cancer. 118(13):3377-3386
➢ Gilleland, J., Reed-Knight, B., Brand, S., Griffin, A., Wasilewski-Masker, K., Meacham,
L., Mertens, A.. (2013) Assessment of family psychosocial functioning in survivors of
pediatric cancer using the PAT2.0.(Psycho-Oncology, 22(9): 2133-2139
➢ Hannisdal E., Arianson H., Braut G.S., Schlichting E., Vinnem J.E. (2013) A risk
analysis of cancer care in Norway: the top 16 patient safety hazards. Joint
Commission Journal on Quality & Patient Safety. 39(11):511-6.
➢ Health Service Executive (2008) Risk Assessment Tool and Guidance. HSE, Dublin.
 References
➢ Kang S., Nam B.H., Park J.Y., Seo S.S., Ryu S.Y., Kim J.W., Kim S.C., Park S.Y.,
Nam J.H. (2012) Risk assessment tool for distant recurrence after platinum-based
concurrent chemoradiation in patients with locally advanced cervical cancer: a
Korean gynecologic oncology group study. Journal of Clinical Oncology.
30(19):2369-74.
➢ Knapke, S.,Nagarajan, R., Correll, J., Kent, D., Burns, K. (2012) Hereditary cancer
risk assessment in a pediatric oncology follow-up clinic. Pediatric Blood & Cancer.
58(1):85-89.
➢ Kohut, A., Orfanelli, T., Poggio, J. L., Gibbon, D., Buckley De Meritens, A., Richard,
S. (2018) Morbidity and Mortality Risk Assessment in Gynecologic Oncology Surgery
Using the American College of Surgeons National Surgical Quality Improvement
Program Database. International Journal of Gynecological Cancer. 28(4):840-847.
➢ Lannering, C., Ernsth Bravell, M., Midlov, P., Ostgren, C., ; Molstad, S. (2016)
Factors related to falls, weight-loss and pressure ulcers - more insight in risk
assessment among nursing home residents. Journal of Clinical Nursing. 25(7-8):940-
950.
 References
➢ Lukaszuk R.F., Dolna-Michno J., Plens K., Czyzewicz G., Undas A. (2018) The
comparison between Caprini and Padua VTE risk assessment models for
hospitalised cancer patients undergoing chemotherapy at the tertiary oncology
department in Poland Wspolczesna Onkologia. 22(1):31-36,.
➢ Mazor K.M., Roblin D.W., Greene S.M., Lemay C.A., Firneno C.L., Calvi J., Prouty
C.D., Horner K., Gallagher T.H., Mazor, K.M.,Roblin, D.W., Greene, S.M., Lemay,
C.A.,Firneno, C. L., Calvi, J., Prouty, C.D., Horner, K., Gallagher, T.H. (2012) Toward
patient-centered cancer care: patient perceptions of problematic events, impact, and
response. Journal of Clinical Oncology, 30(15): 1784-1790.
➢ O'Brien C., Dempsey O.,Kennedy M.J. (2014) Febrile neutropenia risk assessment
tool: improving clinical outcomes for oncology patients. European
Journal of Oncology Nursing. 18(2):167-74.
➢ Pal T., Vadaparampil S.T. (2012) Genetic risk assessments in individuals at high risk
for inherited breast cancer in the breast oncology care setting. Cancer
Control. 19(4):255-66. Pannucci, C.J., Rocconi, R.P. (2016) The limited utility of
currently available venous thromboembolism risk assessment tools in gynecologic
oncology
patients. American Journal of Obstetrics & Gynecology. 215(5):673-674.
 References
➢ Petrucci, P. (2014) Falls prevention in the acute care setting with a focus on the
accurate completion of a falls risk assessment tool: a best practice implementation
project. JBI Database of Systematic Reviews and Implementation Reports.
12(10):234-245.
➢ Petzel S.V.,Vogel R.I., Bensend T., Leininger A., Argenta P.A., Geller M.A. (2013)
Genetic risk assessment for women with epithelial ovarian cancer: referral patterns
and outcomes in a university gynecologic oncology clinic. Journal of Genetic
Counseling. 22(5):662-73.
➢ Richmond J.P (2002) Development and validation of a constipation risk assessment
scale for use in clinical practice. Unpublished thesis. University of Ulster.
➢ Richmond, J.P., & Wright, M.E. (2004) Review of the literature to enable development
of a constipation risk assessment scale. Journal of Clinical Effectiveness in Nursing,
8, 11-25.
➢ Richmond, J.P., & Wright, M.E. (2005) Development of a constipation risk
assessment scale. Journal of Clinical Effectiveness in Nursing, 9, 37-48.
➢ Roper, N., Logan, W., Tierney A. (1980, 2000) The Roper-Logan-Tierney Model of
Nursing. Churchill Livingston: United kingdom
 References
➢ Ropka, M.E., Padilla, G., Gillespie, T. G (2005) Risk Modeling: Applying Evidence-
Based Risk Assessment in Oncology Nursing Practice. Oncology nursing Forum, 32
91) 49-56.
➢ Stargell, L F., Heatherly, S.L. (2018) Managing What Is Measured: A Rural Hospital's
Experience in Reducing Patient Harm. Journal For Healthcare Quality. 40(3):172-176.
➢ Stroud W., Whitworth J.M. Miklic M.Schneider K.E., Finan M.A., Scalici J., Reed E.,
Bazzett-Matabele L., Straughn J.M ., Rocconi R.P. (2014) Validation of a venous
thromboembolism risk assessment model in gynecologic oncology. Gynecologic
Oncology. 134(1):160-3.
➢ Thaler R.H Sunstein C.R. 2008) Nudge. Improving decisions about health, wealth and
happiness. Penguin books: London
➢ Tafur, A.J., Caprini, J. A., Arcelus, J. I. (2017) The limited utility of currently available
venous thromboembolism risk assessment tools in gynecological oncology
patients. American Journal of Obstetrics & Gynecology. 216(3):326.
➢ Townsend, A. B., Valle-Ortiz, M., Sansweet, T. (2016) A Successful ED Fall Risk
Program Using the KINDER 1 Fall RiskAssessment Tool. Journal of Emergency
Nursing. 42(6):492-497.
 References
➢ United Kingdom Oncology Nursing Society (2010) 24 hour triage rapid assessment
and tool kit Helpline Evaluation. UKONS: England
➢ United Kingdom Oncology Nursing Society (2016) 24 hour triage rapid assessment
and tool kit. UKONS: England.
➢ Waters, Nigel J. (2015) Evaluation of drug-drug interactions for oncology therapies:
in vitro-in vivo extrapolation model-based risk assessment. British Journal of Clinical
Pharmacology. 79(6):946-958.
➢ https://about.medicinescomplete.com/publication/stockleys-drug-interactions/