Direct Practice Improvement Project Proposal

DNP-955 Direct Practice Improvement Project Proposal

DNP-955 Direct Practice Improvement Project Proposal

Impacts of Medication errors on 3-4-year-old Leukemia Patients

Submitted by

Bola Odusola-Stephen

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

July 19, 2020

GRAND CANYON UNIVERSITY

Impacts of Medication Errors on 3-4-Year-Old Leukemia Patients

by

Bola Odusola-Stephen

Proposed

July 20, 2020

DPI PROJECT COMMITTEE:

Dr. Lisa Church, EdD, PhD, Manuscript Chair

Genevieve Onyirioha, RN, MSN, FNP, CMSRN, DNP, Committee Member

Table of Contents Chapter 1: Introduction to the Project 7 Background of the Project 8 Problem Statement 10 Purpose of the Project 12 Clinical Question(s) 13 Advancing Scientific Knowledge 14 Significance of the Project 16 Rationale for Methodology 18 Nature of the Project Design 19 Definition of Terms 21 Assumptions, Limitations, Delimitations 22 Summary and Organization of the Remainder of the Project 24 Literature Review 26 Introduction 26 Background 26 Theoretical foundations 29 Review of literature 31 Theme-1 Drug dispensation 31 Subtheme: 1 knowledge deficit 31 Subtheme 2: errors in written orders and formula conversations 32 Theme 2: Drug prescription 36 Subtheme1: errors associated with wrong prescription 38 Subtheme 2: errors associated with medical fillings 39 Theme 3: Parental administration and nurse administration 41 Subtheme1: Parental education on drug administration 41 Subtheme 2: error from ambulatory setting associated with lack of knowledge 44 Summary 52 References 56

Chapter 1:

Introduction to the Project

According to research conducted by James et al. (2006), more than 98 000 deaths were occurring in the hospital, a more significant number than those caused by breast cancer and motor vehicle accidents put together. Most of these deaths that occur in hospitals are because of Medical Errors (Taylor et al., 2006). These medication errors usually happen because of ordering mistakes, monitoring errors, dispensing errors, or administrations errors. They are potential for Adverse Drug Events.

Patients with Acute Lymphoblastic Leukemia are a group of potential victims of Adverse Drug Events that could potentially harm (Walsh et al., 2013). In this project, I will focus on Pediatric Oncology; that is, the effects medication errors could have on patients of Leukemia who are between three and four years old. Pediatric oncology presents a very high-risk area and has potential adverse effects in the case that medication errors present themselves.

Annually, there are about 250,000 cases of children with cancer, with 200,000 being from developing countries. The survival rate of these patients is average at 25%, but the number rises to about 80% in states with underdeveloped health systems. Since there is improved management of these cases because of increased advancement in technology and medical interventions, these cases arise because of medical errors.

Children at the age of 3-4 years are at a high risk of potential Adverse Drug Events because the toxicity of drugs to their weight ratio is high. Also, because chemotherapy drugs are highly toxic, any medication errors could lead to fatal consequences (Goldspiel et al., 2015). Therefore, we must find a way of reducing medication errors in these children, both at the clinics and at home.

Background of the Project

According to the doctor’s prescriptions, pediatric patients with Acute Lymphoblastic Leukemia are subjected to oral dosages of chemotherapy. Typically, they receive their medication both in the hospital and out of the hospital. Chemotherapy drugs are highly toxic, and in the case that they are wrongly administered, there could be potential fatalities. Also, because of the toxicity to the weight ratio of the children who receive chemotherapy drugs, the risk of adverse drug events increases substantially.

Medical errors in administering chemotherapy medication could occur both in the hospital and at home for outpatient children (Walsh et al., 2009). In the hospital, there may be medication errors resulting from failure to reach a proper decision as to which medication or what dosage regimen to give to the patient. There could also be instances of prescribing faults like inappropriate prescription, under prescription, or over-prescription. Other errors that could occur both in the hospital setup and at homes include dispensing the formulation. This happens as a result of giving the wrong drug or the wrong formulation.

The causes of medical errors include poor communication between doctors about the dosage of the drug. Children aged three to four years have lower weight, which means that their dosage is hugely varied (Vázquez‐Cornejo, et al., 2019). Currently, there are no standard dosages for chemotherapy drugs administered to such patients. There could be a medical error resulting from a wrong consensus reached between doctors. There could also be poor communication between the doctors and the parents. Children at this age depend mostly on their parents to administer the drugs to them at home for the case of outpatient patients. In the fact that there is poor communication between doctors and parents, there could be administration errors. Other possible causes of medication errors include wrong drug labels and drug abbreviations that are similar.

Problem Statement

There is a low survival of children who have acute lymphoblastic Leukemia despite the improvement in medicine and technology. This is partly because of the persistent medical errors that occur to these children. Most of the mistakes arise both at the hospital setup and the home setup. Using a quantitative study, this project will determine the impacts of medication errors to 3-4-year-old patients with Leukemia, the probability of medication errors, the type of medication errors, and their severity. This information will help determine solutions that will be important to reduce the instances of adverse drug events resulting from medication errors.

Purpose of the Project

This project aims to study the impacts that Medication Errors have on patients with Acute Lymphoblastic leukemia that are aged between the age of three and four years. Using a quantitative design of the study, this research intends to identify the types of medication errors that are prevalent among this target population both in the hospital and out of the hospital, the causes of these errors and the severity of the impacts these medication errors have on the patients within this age bracket.

Clinical Question(s)

This research is a quantitative study, aimed at finding out the impact of medication errors on children aged three and four years old with ALL. The study will involve clinicians, parents, and guardians of children with ALL and the children with ALL in addition to the researchers. To entirely conduct this research, it will be guided by the following research questions

1. How often to Medical Errors occur to children aged between 3-4 years with ALL?

2. What is the degree of adverse medical events that occur in children with ALL between 3 and 4 years in the case of Medical Errors?

Advancing Scientific Knowledge

A large number of children die and continue to die annually because of persistent cases of medication errors in the healthcare sector. Children have a higher risk of becoming victims of adverse drug events because of medical errors, particularly the pediatric oncology sector (Walsh et al., 2016).

Therefore, it is essential to understand the impacts of medical errors on children aged 3-4 years to understand the causes of these medical errors and their frequency. This will help in the formulation of solutions to deal with this problem. This study aims to determine the impacts of medication errors on children with acute lymphoblastic Leukemia to come up with solutions to these problems.

Significance of the Project

There has been a persistent rise in the number of medically related deaths among the population despite advancements in medicine and medical technology. Research indicates that this is mostly due to the impact of adverse drug effects that are brought about by medical errors. This study aims to understand one such area of medical errors among patients aged between 3-4-year-old with leukemia.

This study will be important in identifying the possible causes of medical errors in pediatric oncology sector. Given the large number of patients who continue to receive treatment both at home and in the hospital, the risk of medical errors increases substantially. It creates the need to come up with feasible solutions to reduce medical errors that may result in loss of lives or permanent damage to the patients.

The results of this study will identify the prevalence of medical errors among the named population, also identifying the main causes of these medical errors. This will provide a foundation for development of practices that will ensure that medical errors among children aged between 3 and 4 years with Acute Lymphoblastic Leukemia is reduced greatly. This study will therefore be important in improving healthcare outcomes in pediatric oncology as a whole.

Rationale for Methodology

To successfully conduct this study, there will be a need for the use of a quantitative design of research. The quantitative research methodology will be essential to quantify the prevalence of medication errors in the children. This frequency will be calculated by using descriptive statistics of the sample.

Thereafter, inferential statistics will be used to make conclusions about a whole population from the sample tested. The degree to which the impacts brought about by these medication errors are lethal will also be calculated by this study and thereafter inferred to the population using statistical calculations.

Nature of the Project Design

This study will take the form of a quantitative design. This study aims to study the impacts of medication errors to pediatric patients with ALL. The4 impacts will be measured on a basis of prevalence and severity. The quantitative phase of this research study, therefore, will be aimed at quantifying the variables of the research. One of the research questions we need to answer is how prevalent are these medical errors. We also need to create a scale through which the severity of the medical errors is measured. A quantitative research h design will be used to accomplish these tasks. The clinicians will note the medical errors among the selected sample in the population and using inferential statistics like ANOVA analysis. We will be in a position to infer these results on the whole population.

A sample of patients aged between 3 and 4 years will be selected from a population of children with a history of Acute Lymphoblastic Leukemia. Their parents will also be part of the research study. Accompanying this sample will be two clinicians who will take notes to determine the causes of medical errors. Medical history records of the patients participating in the study will be accessed, and a history of adverse drug events will be noted. There will be no control group in this research study.

Definition of Terms

Medical Errors. A mistake in the treatment process of a patient that results in or has the potential of resulting in adverse drug events.

Adverse Drug Event. These are negative impacts resulting from the wrongful administration of a drug to a patient. Some of the effects include vomiting, stomach aches, headaches, and even death.

Acute Lymphoblastic Leukemia. This is a type of blood cancer that affects the white blood cells of their victims and is ordinarily genetic.

Assumptions, Limitations, Delimitations

This study assumes that the medication errors identified by the clinicians throughout the observation will continue to do so even after the observation period. Also, the researchers assume that the characteristics of the sample are shared in the population. It is expected that there are no other contraindicating infections among the patients who participate in the disease. The limitations of the study include:

1. There is no way to ascertain the appropriate principles of correct medication administration.

2. There will be limited funding to completely carry out this research study.

The delimitation of this study is:

1. The experiments happen naturally without any intervention of any artificial simulations. This gives the exact picture of the situation at hand.

Summary and Organization of the Remainder of the Project

Chapter 1 introduces the project of the research study. It then goes ahead to provide a background of the project and the statement of the problem. The subsequent section provides an overview of the purpose of this project and its clinical questions. The significance of the project, together with the advance in scientific knowledge, are expounded after that. The rationale for the methodology is described, and the nature of the project is explained briefly. There is a definition of terms used in this project, and the chapter concludes with assumptions, limitations, and delimitations of the study.

Chapter 2 will introduce a survey of current proof on the centrality of the training improvement venture writing audit and the current evidence accessible to direct extend the arrangement. Chapter 3 will portray the strategy, structure, and techniques for this examination. Chapter 4 subtleties how the information was broken down and gave both a composed and realistic rundown of the outcomes. Chapter 5 is an understanding and conversation of the results, as they identify with the current group of proof identified with the training improvement venture theme.

Chapter 2

Literature Review

Introduction

Literature review will conduct views of scholarly article which will entail detail analysis of the information on medical administration errors in children between the ages of 3-4 years. The reviews will be formulated on the major areas of the PICOT question. Children aged 3-4 years have little power or control of their medication and are at great risk of encountering medial errors. The study subthemes will deal with drug prescription, parental administration and drug dispensation.

Background

Medication errors are the most common and the leading medical error in the United States. For a patient to appropriately receive the required treatment in a medical setting, there must be proper prescription of drugs, there is also the need for a pharmacist to effectively understand the doctors writing for them to be able to effectively prescribe the drugs. The nurses are also required to effectively administer the prescribed drugs (Khalek et al., 2015). Although various studies on in-patients show that the medical dispensing errors are also as common as those experienced in the in-patient setting. It is key to point out that in most of the inpatient settings, it is always the role of the patient or caregiver and rather than that of the healthcare professional. It for this reason to acknowledge the fact that potential for medication errors among the ambulatory patients is substantial.

The major problem that has been identified with the medication errors for the young children that are undergoing chemotherapy and administered the leukemia drugs is of great significance (Mulatish, Dwiprahasto & Sutaryo, 2018). The leukemia drugs are by nature toxic and have low therapeutic windows and the results could be very disastrous when an error occurs during its administration. Most of the children under chemotherapy are enrolled in a specific treatment protocol (Neuss et al., 2017). This provides plenty of advantages for the health givers in that it enables them to easily identify, prescribe and avoid medical errors. With proper mechanics to effectively identify these errors, changes in the healthcare systems could help to reduce the medical errors while treatment children aged 3-4 years. It is also important to point out the fact that despite parents of children under outpatient oral chemotherapy could be properly administering the prescribed drugs, the number of required medication and complexity of dosing could be challenging for parents that have not undergone medical training.

Theoretical foundations

A Complex Systems Theory: This addresses the hierarchical structure and the components within a system (Clancy, Effken & Pesut, 2008). The complex system’s theory will be applied to the children aged 3-4 years and suffering from leukemia and undergoing cancer treatment. The dynamic quality of patients together with the advances in science leading to changes in evidence-based practice, complex adaptive systems can best address the physiologic and psycho-social changes that could be experienced by the patient(Clancy, Effken & Pesut, 2008).Health care providers could adapt the complex systems theory or adaptive system while providing care for children with leukemia. The essential part of oncology care for children with leukemia spans from screening to provision of care. Any individual that transitions across the care continuum are identified as a risk assessment, detection, diagnosis and end- of life care (Mulatish, Dwiprahasto & Sutaryo, 2018). The process of assessing the effectiveness and shortcoming attributed to the provision of care can be challenging. The complex system helps establish effective communication between the patient care and recording of the patient data. Understanding and use of the complex systems theory can help to provide best practices in oncology care coordination and transitions while adapting science drive to improve patient outcomes (Clancy, Effken & Pesut, 2008).

Hope Theory is essential in promotion positive coping while offering treatment for children with leukemia. According to Snyder (1989) hope is a goal-directed thinking where people appraise their capability to produce workable routes to goals. Cancer survivors have shown that hope was positively associated with posttraumatic growth (Yuen, Ho, & Chan, 2014). Hope is related to adjustment, coping and social support for children with leukemia. Hope theory is a useful framework that provides clinicians with interventions for providing psychological adjustments for children with leukemia.

Review of Literature

Theme-1 Drug Dispensation

According to Mulatish, Dwiprahasto & Sutaryo (2018) the common medical errors when it comes to treatment of patients with leukemia comes in the administration phase of the medication delivery and during the drug-dispensing phase The major types of errors are attributed to the performance deficit, communication, knowledge deficit, errors in the written orders and medication delivery devices (Tumbelaka, Riono, Sastroasmoro, et al., 2014). The pediatric oncology is a high-risk area and could cause plenty of negative health effects if there is incompetence in personnel, management and lack of the supporting infrastructure. It is thus important of all patients receiving chemotherapy to be investigated.

Subtheme: 1 Knowledge Deficit

According to Phillips & Jones, (2014) there are plenty of exceptions that apply to the conversion formulas that are being used to calculate the medicinal dosage for the children. For example, standing orders for ibuprofen or acetaminophen to reduce fever. One has to determine the patient’s weight in kilograms and multiply by the suggested medication in milligrams per kilogram (Saxena et al., 2018). The unfortunate aspect is that errors could result when the clinicians or care giver calculates weights of patients that are over the 40 kg, the threshold at which to consider the adult dosage and standard pediatric dose conversion formula becomes less useful (Hallböök, Lidström & Pauksens, 2016). Errors can only be minimized if the clinicians are able to adjust the dosage according to the child’s illness and the overall medical condition which include the presence of diseases that affect the drug metabolism (Phillips, amp & Jones, (2014). For the safety of the children there is need to install systems that performs checks and balances to ensure the safety of children suffering from leukemia. This is identified as not being the case (Phillips, amp & Jones, 2014). In a survey that was conducted, by Hallböök, Lidström & Pauksens (2016), the findings were that about half of all the respondents indicated that pharmacists always recalculates the drug dose before filing an order to allow the issuance of the drugs to the children.

According to Pui et al., (2017) the technological advances which involves the use of the computerized physician order entry together with the decision support bar coding could help to minimize the medical administration errors among children age 3 to 4 years (Philips et al., 2014). The adoption of the clinical decision support software enables the clinicians to effectively reference information on medication and dosing parameters, potential drug interactions and known side effects to reduce the risk of fatalities associated with the medical errors among children. It can further help physicians while doing the order entry and help in determining of therapeutic medication dose based on the weight-based calculation and eliminate the human miscalculations. It further provides warning in instances where the dose could be larger or too small for the intended child reduce the harm that could befall the children’s (Lehmann et al., 2015). 

According to Weingart et al., (2018) almost all the pediatric medication requires the pediatrician to perform mathematical calculation something that could be complex. The most common calculations involve the use of fractions, percentages and decimals. While conducting the mathematical tests plenty of research have linked nurses to be poor performers in their mathematical skills (Vázquez-Cornejo et al., 2019).The inability to effectively come up with the best computational method and correct therapeutic volume drug dose could be fatal while treating children with leukemia something that has been linked as the major reason for medical errors. In most of the mathematical tests the new interns and nurses were found to possess poor mathematical skills with pharmacist’s poor computational. The research has indicated that the inability to conceptualize the correct mathematical calculation to be performed and the right mathematical process leading to the solution (Leihman et al., 2015). One of the major sources of error come in when a nurse first calculates the does and the volume to be given which is normally based on the concentration that is made available on the stock. Nurses are in many instances made to perform calculations that are needed in order to come up with the right medicine and lack of math skills needed to solve the problem could lead to fatal outcomes.

Most of the nursing staff do not understand how to apply the calculations in the clinical settings (Rivera‐Luna, 2014) Most of the nurses have not been able to use the calculations since school. While the studies involve physicians, nurses need to be able to effectively perform same calculation. In instances where they are unable to do so, they should not administer any medication. Any misplacement of a decimal point could result on dosing error which could lead to overdosing or under dosing among children with leukemia (Mueller, 2014). Some common consequences of such errors for children suffering with leukemia include transient renal failure, tachycardia, respiratory failure and cardiac arrest. Research points out that that dosage calculations for small children are hugely dependent on the use of decimal point in order to get the right results. Further research findings indicate that people that make tenfold calculation errors are more likely to cause other medication errors (Vázquez-Cornejo et al., 2019). 

According to Mulatsih et al., (2015) there is a varying incidence of medical errors based on the study method and definition. Various studies have shown that most of the medical errors were found as result of wrong prescription and the incompetence among health workers. According to Mulatsih et al., (2016) nursing understanding of medical safety practice is good and continues to improve upon training and use of better reading and interpretation equipment’s. It further points out that despite having good knowledge on the patient safety, this knowledge is not quite enough when it comes to medical errors. The most common medical errors among leukemia patients between the ages of 3 and 11 years were found to result from the chemotherapy errors. Another error found was the roadmap error that was at 27 percent. Supportive care error is another, as well as timing errors, pharmacy errors and clerical errors were among the least causes of medical errors respectively. The errors that are associated with the roadmaps majorly were linked to the use of outdated, or incorrect roadmap, improper sequence of the therapy phase and the deviations of the drug administration from the one that had been scheduled.

Furthermore, the increased chances of the medical errors result from the use of multiple chemotherapy drug for a single patient. It is thus to use a tool that reflects the medical safety practice as a means to reduce medical errors associated with the treatment of the leukemia among children. The number of medical errors has been found to reduce significantly with health care providers adopting the post-intervention compared to the pre-intervention. With fever being the most common symptom among children receiving chemotherapy. The adoption of the simple medical safety program that are obtained from the findings of the local adverse drug events, people are able to reduce young patients’ harms associated with leukemia care. It is necessary to apply the medical safety practice guideline when ordering, dispensing, and transcribing, administering and the monitoring of young patients with leukemia in order to reduce the patients harm during treatment leading to a long-term outcome in patient safety. The limitation presented by the study conducted by Mulatish, Dwiprahasto & Sutaryo (2018) is that it was majorly based on a limited observation period. This necessitates for a periodical review on the implementation of the monitoring program and that other factors such as infection could contribute to bias that is related to the adverse drug events necessitating for the further investigation of the drug effects.

Theme 2: Drug Prescription

Research indicates that medication error occurred majorly in nearly 10 percent of the chemotherapeutic agents prescribed that contained all the ambulatory setting. Research indicates that at least one of the errors occurs in 18.8 percent of the children. The further research findings indicated that one-sixth of the parents do not receive chemotherapeutic regimen indicated. Although a huge percentage of errors were found to relate to administration, there were lots of errors that are linked to prescription. Most of the errors in the prescription have been limited to the ones of clinical significance and are in most essence not linked to alter the probability of the survival. The research by Mulatish, Dwiprahasto & Sutaryo (2018) that children that failed to receive corticosteroid could increase the risk for recurrence and the patients with high instance of mercaptopurine despite having a history of previous neutropenia recorded an increased there was a significant increased risk of infection.

According to Khalek et al., (2015) there is little research on the multisite study errors that are associated with medication use for pediatric oncology patients. The research conducted showed that there was a variance on error rates with sites. The inconsistency depicted by the various sites indicates the actual difference in the detection of errors at home visit or medical record review. Millot, et al., (2014) point out the fact that the parent administration errors were mostly due to miscommunications that existed between the parents and clinicians or when it comes to the changing of children’s doses at home. The errors were linked to the fact that the frequent change of doses, caused the bottle labels to be outdated leading to major parental errors. Geng et al., (2015) point out that most of the errors occurred in the nonchemotherapy medication. This was linked to the fact that most of these children perform frequent visits to their oncologist and that they do not need to inquire more about the nonchemotherapy medication use.

Darlin et al., (2018) pointed out that with the error that was detected in their study, multiple support tools will be necessary to support errors that are associated with home medication use for children with cancer. The failure modes and analytical methods have for a long time been relied on to understand the medical error sources of oral chemotherapy use. Akyay et al, (2014) point out that some communication-based errors could be prevented through the adoption of the hospital around hand offs. The pharmacist case-management which involves technology could be adopted in a means to offer support to home medication use.

Subtheme1: Errors Associated with Wrong Prescription

According to Geng et al., (2015). The medication errors that are associated with pediatric patients between the ages of the 3 and years presents plenty of paucity of data and thus difficult to place the results of the study in the proper contexts. The huge percentage of errors found in this scale are associated with the prescribing errors. Most common errors for children are associated with missing date, this is in addition to the huge percentage of errors that occur during the prescribing stage. The report indicates high rates, which will be much higher in pediatric patients with most of them accounting to 14 of the potential errors that were reported. Moreover, the analysis of comparing the dose versus the weight for selected medication showed that the rate of true errors among the drugs and the patients were much lower (Geng et al., 2015).

According to Mulatish, Dwiprahasto & Sutaryo (2018) medical safety practice is a safe procedure in the medication process. They point out that it is critical to investigate the medical safety practices among cancer children patients considering that they were found to the high risk. There are over 250,000 childhood cancer incidents annually with the highest incidences coming from developing countries. Most of the medical errors for cancer patients were found to be common among patients from developing countries and attributed to the lack of proper facilities and the nursing staff to effectively handle the patients.

According to Schwappach, Pfeiffer, Taxis (2016) there has been improvement of pediatric management of cancer patients upon the improvement of technology equipment used to treat patients. Meanwhile, there has been increased mortality rates for children aged 3 to 11 years with research linked the increased rates to treatment toxicity. Other studies have also shown that the increased incidences of errors are linked to complex combinations and the chemotherapy. According to (Schwappach, Pfeiffer, Taxis (2016) that there is the need to understand the processes of the administration of chemotherapy to reduce the incidence of medical errors and risks that are attributed to the process.

Subtheme 2: Errors Associated with Medical Fillings

According to (Schwappach, Pfeiffer, Taxis (2016) when it comes to chemotherapy transcribing aspects, various studies have shown that there have been a rise in the post-intervention especially in items such as height measures, body mass index, documenting of history of allergy, psychosocial status and chemotherapy planning. Research further indicates that a few aspects such as documenting of the chemotherapy regiment and planning did not meet 100 percent planning. It is key to point out that out of the 49 percent of the drugs ordering stage, 11 percent are done during transcription which is normally inclusive of the frequency, routes or times of deviation being included. There are some aspects of chemotherapy administering that have met 100 percent of the criteria for intervention for patients with leukemia. The post-intervention had the patient’s identity, drug name, drug dose, route of administration and the calculated dose. The study was in line with the previously conducted study which stated that approaching and institution by adopting a multi-discipline system helps to reduce medication errors while the conducting chemotherapy. It also was found that adherence to the drug labeled filings helped in increasing post intervention.

According to Mulatish, Dwiprahasto & Sutaryo (2018) found that chemotherapy preparation by two different health workers that was independently carried out did not conform to the 100 percent standard something they attributed to the inadequate number of nurses compared to the number of patient that resulted in the lack of double checking of chemotherapy drugs. The study further found out that double checking of chemotherapy drugs that has two different independent nurses is a common thing and is believed to significantly reduce medication error among the leukemia and other cancer patients (Schwappach et al., 2016). Other research have also documented that drug verification among the nurses have over time reduced increasing the chances of medical errors among children. Most of the nurses fail to verify the drugs to check for the expiry dates and hence making the drug administration erroneous. It is key to avoid the medical error aspect considering that this medical error is common among 3 percent of medical errors for any patient regardless of age.

The study by Mulatish, Dwiprahasto & Sutaryo (2018) found that chemotherapy monitoring had gotten better of post-intervention compared to pre-intervention. This is of great significance for children that are being administered with more than one drug and are less than five years of aged. These cohorts are majorly prone to chemotherapy medication error while administering. It is key to point out the fact that there is a huge difference when it comes to the documentation and assessment of patients suffering from leukemia. Further research has documented that 94 percent of medical errors that has a low harm potential and the sixty percent of the near-miss medication errors normally occur in the prescribing process. Kaush et al., 2010) points out that the most common cause of the medication errors during prescription normally occur in inappropriate abbreviations, dosing error and legality aspect.

Theme 3: Parental Administration and Nurse Administration

Subtheme1: Parental Education on Drug Administration

According to Mulatish, Dwiprahasto & Sutaryo (2018) the process of the getting consent and family education is essential to increase post-intervention. In the study one aspect that was found not to escalate in post-intervention compared to the pre-intervention was family being given emergency number to be selected for chemotherapy drugs. This was majorly due to the unavailability of the emergency number on the informed consent form and form of family education related to the illness. The process of getting a consent after the provision of clear information given after provision of enough education is important in that communication is essential in the lowering of the medication errors (Schwappach, Pfeiffer & Taxis, 2016).

According to Walsh et al., (2013) with the improvement of the medical care, most of the Americans are taking more of the medications at the homes than ever before. The number of the children that are taking their medication at home have increased in major drug classes. The major reasons for the rising trends in the home consumptions were attributed to the increasing use of the oral agents to treat patients with cancer, rise in the number of cancer survival rates, the rise in the number of children that are in need of ambulatory care and improvement in survival rates for children with the congenital anomalies. There is little research on the error rates that is present in the outpatient setting as a result of medications being administered by patients and their families (Walsh et al., 2013).

There is little research on the outpatient medical consumption at home. It is for this reason that there is little information or understanding on the manner in which medicines are used at home. Most of the studies have majorly relied on retrospective and large databases as a means to reduce the casualty and the risk factors. The medical records review only provide errors that were documented only on record. In studies it only relies on the errors that are reported by parents (Geng et al., 2015). Various research has pointed out this independence on parents’ error reports could at times be erroneous and thus cannot be relied upon. In other studies parents are asked to demonstrate proper dosing of home medication while being at the clinic. Some studies have pointed that the demonstrations that are being provided while at the facility are part of the entire process of home medication use and could be subjected to sampling bias. These studies point out that there is the need to investigate the spectrum errors associated with home medication use and also access the frequency, severity and target education as a means to come up with the most appropriate interventions to the problem (Khalek et al., 2015).

According to Oberoi, Trehan & Marwaha, (2014) the children that children aged between 3 and 4 years are at high risk of experiencing home medication errors. Research indicates that about 10 percent of the missed cancer doses are normally reported to have occurred from home which is a dangerous thing. Underdosing of cancer patients could lead to the fatal results. Walsh et al., (2013) conducted research to determine the types of medical errors that occur at homes for children with cancer. The study performed prospective study from which it was conducted in 3 sites which involved the reviewing of the medical records and bottle labels, and direct observed medication at home. The findings of the research showed that the medication errors for the children of the ages 3 and 4 with almost one in every two parents having been exposed to a medical error while offering treatment at home. In most of these errors the medical administration errors accounted for most of medical errors at home. The type of administration error where the parents administer the wrong dose or medication to the children. The injury rate that is associated to this error was high with the study showing that 4 parents out of the 100 experience high injuries as a result of wrong dose administration.

According to Pui et al, (2018) in all the ways that the patients can be harmed during treatment, medication errors are identified as being the most common means and the most easily preventable. In instances where medication errors occur, the patients are at high risk of death than adults (Saxena et al., 2018). Evidence show that most of the medication errors do harm adult patient. There are over 100 undetected errors. The over 100 medication errors that were not detected are normally as a result of adverse drug event that normally leads to harm or death of the patient. Considering the number of inpatient medication orders that are written on daily basis, there is a high number of the pediatric medication errors that are likely to be staggering (Sheik et al., 2014).

With the current emergence of the research results, there is a great understanding of the impact of medical error on children. Several researchers have found that there are around 4 to 7 per 100 medication orders for children suffering with leukemia. Schmidt, (2019) point out that pediatric outpatients had three times the risk of developing the adverse drug reaction when compared to the adult outpatients. The risk is particularly high if in instances where the medication was used for an off-label indication something that is common among the pediatrics. Despite the study finding plenty of significant errors rates, further findings from other research indicates the frequency of pediatric medication errors from ambulatory settings are much greater. This is attributed to the fewer checks and balances that were put in place as means of preventing these errors.

Subtheme 2: Error from Ambulatory Setting Associated with Lack of Knowledge

According to Sulis et al., (2018) there is need to conduct further research for patient safety in the ambulatory care setting. This has been promoted by the lack of proper policy considering the unique vulnerabilities present in ambulatory settings that exposes the children to the risk death and harm from medical errors (Taverna et al., 2017). The risks to harm were attributed to the glaring lack of knowledge and reliance on ambulatory care something that is not present in the inpatient care (Taverna et al., 2016). Medication errors come in different forms, but they all do not result in the injury or death (Taylor et al., 2016). The medication errors could be defined as being preventable, and the improper use of eh medication could occur during any stage of administering the medication which include the ordering, dispensing, and monitoring. The adverse drug events could occur at any stage of the drug administration.

According to Tremolada et al., (2015) there are different phases of care where medication errors are likely to be experienced in children. In pediatrics, the most common stage where problems could occur is the prescribing or ordering phase which is normally characterized by errors that come with dosing and the administering phase (Tremolada et al., 2016). Taylor et al., (2016) point out that when respondents to patient safety survey to identify the profession that is responsible for the patient safety a huge percentage of the individuals assigned the responsibility to nurses regardless of the factors that contributed to the error. It is thus the role of the nurse that are involved in delivery of care to ensure that they are well-informed on the care or patients and the medications they order.

According to Wang et al., (2017), nurses do play a significant role in the administration of the various medication when it comes to pediatric medication errors. The research points out the fact that despite most errors occur before administration of the drug, the medical errors that are not caught or intercepted by the nurses could be fatal for children living with leukemia (Zannini et al., 2014). The fact that nurses are the one that predominantly administer medications to patients, they are always the last barrier that is present between the mediation errors and the serious harm (Yeh et al., 2014). Nurses are the ones tasked with the responsibility of ensuring that young patients have received the right medication and the most appropriate time. They also have the responsibility of monitoring patients they were assigned to observe the adverse effects of the medication early in time to prevent injury or harm (Whitlow et al., 2015).

The children aged 3 and 4 years are at greater risk of being victims of the medication errors. The medical errors could be fatal considering that they do not have an immature physiology and developmental limitations that can enable them to effectively communicate or self-administer medications as it relates to adults (Schwappach, Pfeiffer, Taxis et al., 2016). Another factor for being victims of medical errors is that most of the formulations for treating Leukemia are meant for adults. It thus means that in most of the instance’s pediatric indications and the dosage guidelines are not always contained in the medication (Mulatsih, Dwiprahasto & Sutaryo, 2018). The drugs are majorly in the form of formulations that are normally weight-based. This means that in order for any drug to be used by children, there is the issuance of safe dosages which are normally fractions of adult-based drugs which must also be calculated (Zang et al., 2014).

According to Mulatsih, Dwiprahasto & Sutaryo, (2018) the process of determining the pediatric dosages is complex. The complexity is mostly because one uses the child weight. The children that take these types of medications are at high risk of being involved in the medication errors compared to the children that take medication that do not required any calculations. In instances of reduced calculations, the risk is decreased significantly (Wang et al., 2017). The risk is much higher if the children are in ICUs, the ones that are in EDs and if seriously ill between the 4 am and 8 am hours or the weekends, children whose weight have not been documented and the ones that are receiving IV medication.

Summary

There are of the practical steps that nurses can undertake in order to improve pediatric medication safer for patients with leukemia (Inaba et al., 2017). While many of the things would begin in a good way to start. Understanding of the near misses is the key to managing medication errors (Cooper & Brown, 2015). Various research has indicated that the total number of the reported medical errors are few and it is difficult to determine these medical errors in its actual sense. The situation is even worse for the children aged between 3 and 4 years. Furthermore, there are various underreport that if they fear reprisal or if they are uncertain of the definition of error. It is the role of the managers to ensure that the nurses among other health providers are not punished for the mistakes, that error is encouraged with the hiding mistakes is discouraged.

The lack of knowledge on the kind of medication and how to administer it has been linked by several studies as the major reason for the rise in the medical errors. To effectively manage leukemia among the children aged 3 and 4, it is key for the nurses and the caregivers to have knowledge of the medication that is being administered for the child (Hunger & Mullighan, 2015). They need to understand the medication that is being used, whether the medication is appropriate for the child, the recommended therapeutic dosage range and how these patients could respond if there were adverse reactions (American Society of Hospital Pharmacists, 2018) In any instance where one is not concerned on the dosage, it is key to ask questions as a means to gain more insights to the patient’s interests (Reinhardt et al., 2019). The lack of information or knowledge on drugs being administered has been found to contribute to fifteen percent of medication administration errors among nurses that need to take advantage of pharmacists knowledge when in to preparing, administering and monitoring drug therapy (Hinojosa‐Amaya et al., 2016).

In instances of medication is prescribed for an off-label use in a child, It important to check the suggested dosage and duration of treatment with a pharmacist, in areas where there appropriate references with the current edition of physician desk reference in a computerized drug order entry system. In instances where medication is prescribed in an off-label use, it could be difficult to find the correct dose (Maaskant et al. 2015). With the improvement of knowledge of the medication and plenty of medication increases, nurses continue to improve their knowledge on means to ensure medication errors. There is need to establish higher medication errors and nurses should be cautious when administering them and double-check any orders (Tuckuviene et al. 2016).

References

Goldspiel, B., Hoffman, J. M., Griffith, N. L., Goodin, S., DeChristoforo, R., Montello, C. M., … & Patel, J. T. (2015). ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. American Journal of Health-System Pharmacy, 72(8), e6-e35. Retrieved from /orders/academic.oup.com/ajhp/article- abstract/72/8/e6/5111768

Taylor, J. A., Winter, L., Geyer, L. J., & Hawkins, D. S. (2006). Oral outpatient chemotherapy medication errors in children with acute lymphoblastic Leukemia. Cancer, 107(6), 1400- 1406. Retrieved from /orders/acsjournals.onlinelibrary.wiley.com/doi/abs/10.1002/cncr.22131

Vázquez‐Cornejo, E., Morales‐Ríos, O., Juárez‐Villegas, L. E., Islas Ortega, E. J., Vázquez‐Estupiñán, F., &Garduño‐Espinosa, J. (2019). Medication errors in a cohort of pediatric patients with acute lymphoblastic leukemia on remission induction therapy in a tertiary care hospital in Mexico. Cancer medicine, 8(13), 5979-5987. Retrieved from /orders/onlinelibrary.wiley.com/doi/abs/10.1002/cam4.2438

Walsh, K. E., Dodd, K. S., Seetharaman, K., Roblin, D. W., Herrinton, L. J., Von Worley, A., … &Gurwitz, J. H. (2009). Medication errors among adults and children with cancer in the outpatient setting. Journal of Clinical Oncology, 27(6), 891-896. Retrieved from /orders/www.academia.edu/download/39833209/891.pdf

Walsh, K. E., Roblin, D. W., Weingart, S. N., Houlahan, K. E., Degar, B., Billett, A… & Mazor, K. M. (2013). Medication errors in the home: a multisite study of children with cancer. Pediatrics, 131(5), e1405-e1414. Retrieved from /orders/pediatrics.aappublications.org/content/131/5/e1405.short

Walsh, K., Ryan, J., Daraiseh, N., & Pai, A. (2016). Errors and nonadherence in pediatric oral chemotherapy use. Oncology, 91(4), 231-236. Retrieved from /orders/www.karger.com/Article/Abstract/447700

References

Akyay, A., Olcay, L., Sezer, N., & Sönmez, Ç. A. (2014). Muscle strength, motor Byrd, J. C., Jones, J. J., Woyach, J. A., Johnson, A. J., & Flynn, J. M. (2014). Entering the era of targeted therapy for chronic lymphocytic leukemia: impact on the practicing clinician. Journal of Clinical Oncology, 32(27), 3039.

American Society of Hospital Pharmacists. (2018). ASHP guidelines on preventing medication errors in hospitals. Am J Health Syst Pharm.;75(19):1493‐1517.

Cooper SL, Brown PA. (2015) Treatment of pediatric acute lymphoblastic leukemia. Pediatr Clin North Am.;62(1):61‐73. 

Clancy, T.R., Effken, J.A., & Pesut, D. (2008). Applications of complex systems theory in nursing education, research, and practice. Nursing Outlook, 56, 248–256.e3. /orders/doi.org/10.1016/j.outlook.2008.06.010

Darling, S. J., De Luca, C., Anderson, V., McCarthy, M., Hearps, S., & Seal, M. L. (2018). White matter microstructure and information processing after chemotherapy-only treatment for pediatric acute lymphoblastic leukemia. Developmental neuropsychology, 43(5), 385-402.

Hallböök, H., Lidström, A. K., & Pauksens, K. (2016). Ciprofloxacin prophylaxis delays initiation of broad-spectrum antibiotic therapy and reduces the overall use of antimicrobial agents during induction therapy for acute leukemia: a single- center study. Infectious Diseases, 48(6), 443-448.

Hinojosa‐Amaya JM, Rodríguez‐García FG, Yeverino‐Castro SG, Sánchez‐Cárdenas M, Villarreal‐Alarcón MÁ, Galarza‐Delgado DÁ.(2016) ;. Medication errors: electronic vs paper‐ based prescribing. Experience at a tertiary care university hospital. J Eval Clin Pract. 2016;22(5):751‐754.

Hunger SP, Mullighan CG. (2015). Acute lymphoblastic leukemia in children. N Engl J Med. 373(16):1541‐1552.

Inaba H, Pei D, Wolf J, et al. (2017). Infection‐related complications during treatment for childhood acute lymphoblastic leukemia. Ann Oncol. ;28(2):386‐ 392.

Kaushal R, Goldmann DA, Keohane CA, et al. (2010). Medication errors in paediatric outpatients. Qual Saf Health Care.;16:1–6. 

Khalek, E. R. A., Sherif, L. M., Kamal, N. M., Gharib, A. F., & Shawky, H. M. (2015). Acute lymphoblastic leukemia: Are Egyptian children adherent to maintenance therapy?. Journal of cancer research and therapeutics, 11(1), 54.

Geng, C., Moteabbed, M., Xie, Y., Schuemann, J., Yock, T., & Paganetti, H. (2015). Assessing the radiation-induced second cancer risk in proton therapy for pediatric brain tumors: the impact of employing a patient-specific aperture in pencil beam scanning Physics in Medicine & Biology, 61(1), 12.

Lehmann CU, (2015); Council on Clinical Information Technology. Pediatric aspects of inpatient health information technology systems. Pediatrics. 2015;135(3). Available at: www.pediatrics.org/cgi/content/full/135/3/e756pmid:25713282

Lehmann CU, O’Connor KG, Shorte VA, Johnson TD (2015). Use of electronic health record systems by office-based pediatricians. Pediatrics. 2015;135(1). Available at: www.pediatrics.org/cgi/content/full/135/1/e7pmid:25548325

Lipitz-Snyderman A, Classen D, Pfister DG et al. (2017). Performance of a trigger tool for identifying adverse events in oncology.J Oncol Pract. 2017; 13: 223-230

Millot, F., Guilhot, J., Baruchel, A., Petit, A., Bertrand, Y., Mazingue, F., … & Sirvent, N. (2014). Impact of early molecular response in children with chronic myeloid leukemia treated in the French Glivec phase 4 study. Blood, 124(15), 2408-2410.

Maaskant JM, Vermeulen H, Apampa B, et al. (2015). Interventions for reducing medication errors in children in hospital. Cochrane Database Syst Rev.;(3):CD006208

Mulatsih S, Dwiprahasto I, Soetaryo (2016)Pemahaman perawat mengenai medication errors di Bangsal Perawatan Kanker Anak RSUP Dr. Sardjito. Indonesian J Cancer. ;9:111–7. 

Mulatsih S, Dwiprahasto I, Soetaryo Pemahaman perawat mengenai medication safety practice di Bangsal. Sari Pediatri. 2016;17:463–8

Mueller BU. (2014). Quality and safety in pediatric hematology/oncology. Pediatr Blood Cancer. 2014;61:966‐969.

Mulatsih, S., Dwiprahasto, I., & Sutaryo (2018). Implementation of Medication Safety Practice in Childhood Acute Lymphoblastic Leukemia Treatment. Asian Pacific journal of cancer prevention : APJCP, 19(5), 1251–1257. /orders/doi.org/10.22034/APJCP.2018.19.5.1251

Murphy, B. R., Roth, M., Kolb, E. A., Alonzo, T., Gerbing, R., & Wells, R. J. (2019). Development of acute lymphoblastic leukemia following treatment for acute myeloid leukemia in children with Down syndrome: A case report and retrospective review of Children's Oncology Group acute myeloid leukemia trials. Pediatric blood & cancer, e27700.

Neuss, M. N., Gilmore, T. R., Belderson, K. M., Billett, A. L., Conti-Kalchik, T., Harvey, B. E. … & Olsen, M. (2016). 2016 updated the American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards, including standards for pediatric oncology. Journal of oncology practice, 12(12), 1262-1271

Oberoi S, Trehan A, Marwaha RK. (2014).  Medication errors on oral chemotherapy in children with acute lymphblastic leukemia in a developing country. Pediatr Blood Cancer.; 61(12): 2218‐ 2222.

Padmini, C., & Bai, K. Y. (2014). Oral and dental considerations in a pediatric leukemia patient. ISRN hematology, 2014.

Pui, C. H., Pei, D., Raimondi, S. C., Coustan-Smith, E., Jeha, S., Cheng, C. … & Inaba, H. (2017). Clinical impact of minimal residual disease in children with different subtypes of acute lymphoblastic leukemia treated with response-adapted therapy. Leukemia, 31(2), 333.

Phillips, F., & Jones, B. L. (2014). Understanding the lived experience of Latino adolescent and young adult survivors of childhood cancer. Journal of cancer survivorship, 8(1), 39

48.

Preacher K. J. Hayes A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879–891.

Reinhardt H, Otte P, Eggleton AG, et al. (2019). Avoiding chemotherapy prescribing errors: analysis and innovative strategies. Cancer. 125(9):1547‐1557.

Rivera‐Luna R, Shalkow‐Klincovstein J, Velasco‐Hidalgo L, et al. (2014). Descriptive epidemiology in Mexican children with cancer under an open national public health insurance program. BMC Cancer. 2014;14:790.

 Schwappach DLB, Pfeiffer Y, Taxis K. (2016); Medication double-checking procedures in clinical practice:a cross-sectional survey of oncology nurses’experiences’. BMJ Open. 2016;6:1–10. 

Snyder C. R. (1989). Reality negotiation: From excuses to hope and beyond. Journal of Social and Clinical Psychology, 8, 130–157.

Tumbelaka AR, Riono P, Sastroasmoro S, et al. (2014) Pemilihan uji hipotesis. In: Sastroasmoro S, Ismael S, editors. ‘Dasar-dasar Metodologi Penelitian Klinis’. Jakarta: Sagung Seto; 2014.

Saxena, A., Jain, G., & Gupta, R. (2018). Comment on: Effectiveness of antibacterial prophylaxis during induction chemotherapy in children with acute lymphoblastic leukemia. Pediatric blood & cancer, 65(8), e27044.Seif, A. E., Walker, D. M., Li,Y., Huang, Y. S. V., Kavcic,M., Torp, K., … & Aplenc, R. (2015). Dexrazoxane exposure and risk of secondary acute myeloid leukemia in pediatric oncology patients. Pediatric blood & cancer, 62(4), 704-709.

Sheikh, H. I., Joanisse, M. F., Mackrell, S. M., Kryski, K. R., Smith, H. J., Singh, S. M., & Hayden, E. P. (2014). Links between white matter microstructure and cortisol reactivity to stress in early childhood: Evidence for moderation by parenting. NeuroImage: Clinical, 6, 77-85.

Schmidt, C. W. P. (2019). Administration of a Pediatric Oncologic Pharmacy: From the Purchase of the Drugs to the Dispensation. In Pediatric Oncologic Pharmacy (pp. 107-116). Springer,Cham.

Sulis, M. L., Blonquist, T. M., Stevenson, K. E., Hunt, S. K., Kay‐Green, S., Athale, U. H., …& Leclerc, J. M. (2018). Effectiveness of antibacterial prophylaxis during induction chemotherapy in children with acute lymphoblastic leukemia. Pediatric blood & cancer, 65(5), e26952.

Schwappach DLB, Pfeiffer Y, Taxis K. (2016); Medication double-checking procedures in clinical practice:a cross-sectional survey of oncology nurses’experiences’. BMJ Open. ; 6:1–10. 

Taverna, L., Tremolada, M., Bonichini, S., Tosetto, B., Basso, G., Messina, C., & Pillon, M. (2017). Motor skill delays in pre-school children with leukemia one year after treatment:Hematopoietic stem cell transplantation therapy as a significant risk factor. PloS one, 12(10), e0186787.

Taverna, L., Tremolada, M., Bonichini, S., Basso, G., & Pillon, M. (2016). Adaptive functioning of preschooler children with leukemia post one year of therapies compared with sane peers. Br.J. Educ. Soc. Behav. Sci, 18, 1-15.

Taylor, J. A., Winter, L., Geyer, L. J., & Hawkins, D. S. (2016). Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia. Cancer, 107(6), 1400-1406.

Toft, N., Bergen, H., Abrahamsson, J., Griškevičius, L., Hallböök, H., Heyman, M., … & Quist- Paulsen, P. (2018). Results of NOPHO ALL2008 treatment for patients aged 1–45 years with acute lymphoblastic leukemia. Leukemia, 32(3), 606.

Tremolada, M., Bonichini, S., Basso, G., & Pillon, M. (2015). Coping with pain in children with leukemia. International Journal of Cancer Research and Prevention, 8(4), 451.

Tremolada, M., Bonichini, S., Basso, G., & Pillon, M. (2016). Post-traumatic stress in parents of children with leukemia: Methodological and clinical considerations. Comprehensive Guide to Post-Traumatic Stress Disorders, 579- 597.

Tuckuviene R, Ranta S, and Albertsen BK, et al. (2016). Prospective study of thromboembolism in 1038 children with acute lymphoblastic leukemia: a Nordic Society of Pediatric Hematology and Oncology (NOPHO) study. J Thromb Haemost.;14(3):485‐494

Vázquez-Cornejo E, Morales-Ríos O, Juárez-Villegas LE, Islas Ortega EJ, Vázquez- Estupiñán F, Garduño-Espinosa J. (2019). Medication errors in a cohort of pediatric patients with acute lymphoblastic leukemia on remission induction therapy in a tertiary care hospital in Mexico. Cancer Med. 2019;8(13):5979- 5987. doi:10.1002/cam4.2438

Walsh, K. E., Roblin, D. W., Weingart, S. N., Houlahan, K. E., Degar, B., Billett, A., Keuker, C., Biggins, C., Li, J., Wasilewski, K., & Mazor, K. M. (2013). Medication errors in the home: a multisite study of children with cancer. Pediatrics, 131(5), e1405–e1414. /orders/doi.org/10.1542/peds.2012- 2434

Wang, Y., Liu, Q., Yu, J. N., Wang, H. X., Gao, L. L., Dai, Y. L., … & Mu, G. X. (2017). Perceptions of parents and pediatricians on pain induced by bone marrow aspiration and lumbar puncture among children with acute leukemia: a qualitative study in China. BMJ Open, 7(9), e015727.

Weingart, S, Zhang, L, Sweeney, M & Hassett, M. (2018). Chemotherapy medical errors. The Lancet. /orders/www.thelancet.com/journals/lanonc/article/PIIS1470-2045(18)30094-9/fulltext

Whitlow, P. G., Saboda, K., Roe, D. J., Bazzell, S., & Wilson, C. (2015). Topical analgesia treats pain and decreases propofol use during lumbar punctures in a randomized pediatric leukemia trial. Pediatric blood & cancer, 62(1), 85-90.

Yeh, T. C., Liu, H. C., Hou, J. Y., Chen, K. H., Huang, T. H., Chang, C. Y., & Liang, D. C. (2014). Severe infections in children with acute leukemia undergoing intensive chemotherapy can successfully be prevented by ciprofloxacin, voriconazole, or micafungin prophylaxis. Cancer, 120(8), 1255- 1262.

Yuen A. N. Ho S. M. Chan C. K. (2014). The mediating roles of cancer-related rumination in the relationship between dispositional hope and psychological outcomes among childhood cancer survivors. Psychooncology, 23, 412–419. doi: 10.1002/pon.3433

Zannini, L., Cattaneo, C., Jankovic, M., & Masera, G. (2014). Surviving childhood Leukemia in a Latin culture: An explorative study based on young adults’ written narratives. Journal of psychosocial oncology, 32(5), 576-601.

Zhang, F. F., Rodday, A. M., Kelly, M. J., Must, A., MacPherson, C., Roberts, S. B., … K. (2014). Predictors of being overweight or obese in survivors of pediatric acute lymphoblastic leukemia (ALL). Pediatric blood & cancer, 61(7), 1263-1269.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS – DNP-955 Direct Practice Improvement Project Proposal

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. DNP-955 Direct Practice Improvement Project Proposal

• Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

• Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

• APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

• Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source. DNP-955 Direct Practice Improvement Project Proposal

• LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

• Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading. DNP-955 Direct Practice Improvement Project Proposal

• Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. DNP-955 Direct Practice Improvement Project Proposal

• Guarantee

  

• Zero Plagiarism
• On-time delivery
• A-Grade Papers
• Free Revision
• 24/7 Support
• 100% Confidentiality
• Professional Writers

• Services Offered

• Custom paper writing
• Question and answers
• Essay paper writing
• Editing and proofreading
• Plagiarism removal services
• Multiple answer questions

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

Looking for a Similar Assignment? Order a custom-written, plagiarism-free paper