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CC BY 4.0 · Indian J Med Paediatr Oncol
DOI: 10.1055/s-0045-1811575
Original Article

Learning from Errors and Mishaps: An Audit of Hospital Morbidity Events from a Medical Oncology Unit

Singuluri Sandhya
1   Departments of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Yadav Nisha
1   Departments of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Sunantha Pichai
2   Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Narayanan Priyanka
1   Departments of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Murugaiyan Sarvanapriya
1   Departments of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Smita Kayal
1   Departments of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Prasanth Ganesan 
1   Departments of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
,
Biswajit Dubashi 
1   Departments of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Abstract

Introduction

Morbidity, an unwanted and often preventable event, is an integral part of cancer treatment. Various morbidity events can contribute to significant toxicities and delay treatment. We intend to describe a novel morbidity data collection methodology to identify all possible morbidity events, learn from mishaps, and improve internal standards to prevent future occurrences.

Objective

This article aims to understand the various morbidity events occurring during chemotherapy among patients undergoing treatment in the medical oncology unit.

Materials and Methods

Data were collected from January 2019 to March 2020 from the department of medical oncology of a tertiary cancer center. The treating team notified the morbidity events via a closed WhatsApp group. These events were prospectively recorded by a nurse who updated various events from all work areas in a defined Excel sheet.

Results

A total of 2,551 patients were registered for treatment from January 2019 to March 2020. A total of 864 morbidity events were recorded: 423 (48%) catheter-related events, 54 (6%) medical errors, 45 (5%) transfusion reactions, 210 (25%) miscellaneous morbidity events, and 31 (3%) unknown events. The median age was 26 years (1–70), with the majority of the events seen among adolescent young adult patients, 422 (48.9%). Catheter-related events were found in the majority, with central line–associated bloodstream infection being one of the significant causes of morbidity and catheter removal (13.3%). Hence, a catheter maintenance team was introduced. Catheter maintenance was successful in 36.8% (117/426).

Conclusion

A structured, uniform, and prospective record of the morbidity events during treatment is essential to understanding errors, which can provide an opportunity to rectify future events. The periodic audit of events can help in establishing standardized operating procedures to minimize error and maximize safety.

Key message

Morbidity event definitions and recognition plus reporting are essential to understand and prevent future events.

  1. What is already known: Mishaps and side effects occur concurrently with any patient care or treatment.

  2. What this study adds: Novel method of data collection and reporting from all key areas of work, uniform definitions, and systematic categorization of events with emphasis on near and never miss events.

  3. How this study might affect research practice or policy: Will enlighten on the major morbidity events possible and ways to prevent. Important teamwork and novel data collection methodology.

Keywords

morbidity - chemotherapy-related toxicity - central line-associated bloodstream infection - transfusion reaction

Data availability Statement

Data are available on request from the corresponding author.


Patients' Consent

Patient consent is not applicable. Waiver of consent is obtained from IEC, Jawaharlal Institute of Postgraduate Medical Education and Research.




Publikationsverlauf

Artikel online veröffentlicht:
08. September 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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