Patient safety is at the core of Dana-Farber's mission and
vision and the Institute has been a leader in advancing safe
practices and reducing the risk of medical error. We believe that
health care organizations need to learn from accidental errors and
injuries, in order to make care safer. Read more about Dana-Farber's patient safety research and initiatives.
The Longitudinal Medical Record (LMR) is a Web-based electronic
health record used at Dana-Farber and across the Partners
healthcare system. Dana-Farber clinicians use the LMR to maintain
patient records, order tests and medications, review results, and
share critical medical information with other clinicians.
The medication safety features include the ability to avoiding
potentially dangerous drug interactions and the ordering of
unnecessary drugs and tests. Together, these features help to
ensure safety, quality, and efficiency.
Dana-Farber is working toward implementing a fully electronic
system for recording and tracking medication, from initial order to
Our goal is to create a "closed loop of medication" that uses
bar coding to follow an order from the point it is entered into the
system, through preparation and dispensing by the pharmacy, to
administration by a nurse.
All patients now receive identification wristbands printed with
a bar code. Products used to prepare chemotherapy agents and other
medications at Dana-Farber's pharmacies are also bar coded and
recorded in a computer system programmed to catch errors.
When the system is fully operational, nurses will be able to
scan the code on a patient's wristband with a hand-held scanner,
calling up an electronic medication record on a laptop computer.
They will then scan the label on the medication container. The
system will alert them if a mismatch has occurred.
Serious reportable events (SREs) are a group of 28 types of
incidents that can affect hospitalized patients. These events,
defined by a group of health care organizations called the National
Quality Forum, include:
Although these events are rare, many are serious and they are
often, though not always, preventable.
Dana-Farber reports SREs to the
Massachusetts Department of Public Health and Board of Registration
Lessons learned and actions to prevent future events:
Dana-Farber conducted an employee survey in 2007 to assess our
patient safety culture. The safety culture of an organization tells
us about employees' perceptions and judgments about the quality of
communication, teamwork, collaboration, and fairness.
Understanding our safety culture can help us to compare
ourselves against national benchmarks, to identify strengths and
weaknesses, and to create a baseline against which we can measure
improvements. Clinical staff participated in the survey, using a
tool developed by the US Agency for Healthcare Research and
Dana-Farber met or exceeded national benchmark performance of
other teaching hospitals in 14 of 19 areas. Our results were
particularly strong in response to questions about organizational
learning, supervisor/manager expectations and actions promoting
patient safety, and management support for patient safety.
Our responses also showed opportunities for improvement in
management of the volume and complexity of patients in our clinical
areas, and in the need to communicate more effectively with staff
members about safety incidents and to share the results of
improvement efforts. We are actively addressing these concerns.
High-performing organizations standardize the way they do
things. If there is one best way to deliver care for a certain
disease or condition, then that approach should be done the same
way, every time. In fact, standardization of care captures best
practice and helps clinicians recognize when a customized approach
Dana-Farber clinicians developed and use common templates for
delivering care. These treatment plans are incorporated in our
electronic medication ordering systems, and they are updated
regularly, based on the latest available research. This approach
ensures that the best care is delivered the same way every
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