• Patient Safety

    Initiatives

    The Center for Patient Safety has four priority areas, reflecting a strong interest in and commitment to the role that patients can play in creating safe care.

    Medication safety

    Medication errors are the most common source of medical injury, and a special hazard in cancer care. The Center supports the longstanding, Institute-wide commitment to medication safety.

    Medication reconciliation is a standardized process for verifying and updating patients' current medications, with the goal of preventing medication errors. Beginning with a complete list of the patients' current medications, including over-the-counter drugs, the list is re-checked periodically and at transitions in care. Any discrepancies are corrected and recorded.

    The Center for Patient Safety, in collaboration with clinical and administrative staff throughout Dana-Farber, created a novel method in which patients participate with providers in the process. The goal of the initiative is to ask all established patients to review their medication list at regular office visits, and for providers to verify the updated list. Center for Patient Safety staff members gather data to evaluate the process and look for opportunities for improvement.

    Materials

    View some of the documents and training materials used in Dana-Farber's medication reconciliation process.

    Introductory letter to patients

    In English
    In Russian
    In Spanish  

    Instructions for pharmacists

    Pharmacist guidelines  

    Read more about medication reconciliation in publications and alerts from leading patient safety organizations.

    Joint Commission on Accreditation of Healthcare Organizations

    Sentinal Alert #35 identifies types of errors in reconciliation and describes strategies to reduce risk.

    JCAHO's 2007 Patient Safety Goals include a requirement that hospitals institute a medication reconciliation program.

    Massachusetts Coalition for the Prevention of Medical Errors

    Massachusetts hospitals have joined in a state-wide collaboration to reduce medication errors by adopting medication reconciliation safe practices. Read an overview of the initiative and consensus group Safe Practice Recommendations.

    MCPME Overview
    MCPME Safe Practice Recommendations  

    Institute for Healthcare Improvement (IHI)

    IHI tells success stories of hospitals that have instituted medication reconciliation systems, and summarizes the risks of adverse drug events that result from inaccurate patient medication records. Read the IHI report .

    Institute for Safe Medication Practices

    An ISMP Medication Safety Alert describes errors that result from failed communication and outlines steps to implement JCAHO's medication reconciliation safety goal. Read Building a Case for Medication Reconciliation .

    Safe prescribing practices

    Commonly used abbreviations in drug prescriptions can be confusing to nurses and pharmacists and lead to mistakes. A task force from Dana-Farber and Brigham and Women's Hospital developed new standards and procedures to eliminate unapproved abbreviations in hand-written records and communications.

    Medication safety information

    Center staff developed a brochure to help Dana-Farber patients use medications safely [1.2.5.1] and avoid drug reactions during their treatment. The brochure includes a form to list medications, allergies, and emergency contacts.

    Communication and teamwork

    High-risk work environments require precise teamwork and high levels of performance. The teamwork and communication strategies of industries like aviation and nuclear power offer lessons for the medical workplace.

    Teamwork training for patients

    Dana-Farber Cancer Institute supports the role of patients as members of their healthcare team. The Center for Patient Safety developed a campaign to help patients learn the communication skills used by successful teams in high-performance industries. Nursing staff and patients contributed to the design of the curriculum and educational materials.

    Teamwork for Safe Care

    Dana-Farber has many systems in place to enhance the safety of our patients. But one of the most important things you can do to make your experience even safer is to speak up if something doesn't seem right.

    You and your family are important members of your healthcare team, which includes doctors, nurses, social workers, and others. Good communication is the foundation of a successful team. Your experience will be safer if you: Check, Ask, Notify

    You CAN help Dana-Farber safely care for you: Check, Ask, Notify.

    Check

    At every visit to Dana-Farber, check to make sure things look right. For example, is your chemotherapy the same color it was last time? Are your pills the same shape? If you notice anything out of the ordinary, we want to know about it.

    Check to make sure you've understood your caregivers by repeating information they have given you. Dana-Farber welcomes family members and friends. A companion can offer a second set of eyes and ears, helping to check on things for you or your child.

    Ask

    Everyone on your team, including you, should understand instructions and explanations. Team members should remind one another about important safety issues.

    Ask what side effects to expect from your medications, and what to do if you have them.

    Ask your healthcare providers if they washed their hands. Dana-Farber has some of the best hand-washing rates in the country, but some staff members may forget once in awhile.

    Ask your doctor or nurse to repeat anything you didn't hear or understand.

    Ask any other questions you have about your treatment or care.

    Notify

    Team members are trained to speak up when they see danger or think someone's mistake might cause an accident. They also share information that will help the team perform better.

    As a member of your team you CAN:

    Notify your caregivers about any problems you've had in between visits.

    Notify your nurse if your doctor made any last-minute changes to your treatment. Even though your caregivers work as a team, you can help make sure everyone has the same information.

    Notify your caregivers about any side effects you have experienced since your last visit, or anything else that might affect your treatment today.

    Infection Control

    Hand hygiene is the most effective way to prevent the spread of infection in hospitals.

    Center staff monitor hand washing practices in the adult infusion units at Dana-Farber, and on the inpatient oncology units at Brigham and Women's Hospital.

    The Center works with nursing leaders to identify opportunities for improvement and to support projects to increase adherence to hand hygiene guidelines. With the help of the Communications department, a hospital-wide campaign in 2006 encouraged proper hand hygiene practices

    Diagnostic Errors

    Relatively little is known about medical errors that result in missed and delayed diagnoses. However, missed and delayed diagnoses are an ongoing risk to patient safety and a growing source of malpractice liability. Center for Patient Safety staff members led a chart review study of adult patients diagnosed with breast cancer from 1999-2004.

    Pain diagnosis

    Center staff found that clinical staff reliably screen patients for pain in over 96 percent of visits. Current initiatives seek to maintain high standards and ensure communication of critical results to front line providers.

     
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