• Patient Safety Resources

    Patient Safety Rounding Toolkit

    Over the past four years, Dana-Farber has developed and evaluated a model of Patient Safety Rounds that we believe will be of benefit to other healthcare organizations. Through our program evaluation and ongoing experiences, we have learned that Patient Safety Rounds is a powerful tool that can help organizations achieve their safety objectives.

    The Patient Safety Rounds program involves staff, such as the Risk Manager, requesting and obtaining information about actual and potential safety problems from staff. In addition, patients and family members interview current patients about their perceptions of safe care. At Dana-Farber, the discussions and patient interviews conducted through Patient Safety Rounds have yielded information and insights that have led to numerous improvements and a safer patient care environment.

    In this toolkit you will find organizational assessments, program guidelines, training materials, and other documents and tools to help you design and implement a Patient Safety Rounds program for your institution. See Patient Safety Rounding Toolkit below.

    Online Resources

    View an assortment of links to Web sites that deal with matters related to patient safety. Check out Online Resources below.

    Medication safety in oncology: Vincristine

    Vincristine, a chemotherapy drug used in the treatment of leukemias, lymphomas, and a variety of solid tumors, may cause nerve toxicity. See Vincristine below.

    Patient safety in oncology: Selected references

    View a collection of papers that address safety topics in cancer care. See Selected References below.

    Patient Safety Rounding Toolkit

    Implementing Dana-Farber Cancer Institute Patient Safety Rounds in Your Organization - A Toolkit

    Toolkit Overview and Rationale

    Toolkit coverOver the past decade, Dana-Farber Cancer Institute (DFCI) has worked to create an organizational culture that places a high priority on patient safety and on patient- and family-centered care. Today, an assessment of how an action or process will impact the safety of patients and families is a routine part of DFCI's decision-making process, and patients and families participate in decision-making at every level of the Institute.
    Toolkit Overview and Rationale for a Patient Safety Rounds Program 

    Organizational Assessment

    A Patient Safety Rounds program is most easily implemented in organizations that demonstrate a commitment to patient safety and patient- and family-centered care. In this section, we provide assessment instruments that can be used by leaders to evaluate their organization's culture and determine whether it promotes patient safety and patient- and family- centered care. Based on their findings, leaders will be able to decide whether their institution is ready to introduce a Patient Safety Rounds program.

    Additionally, an institution may consider implementing principles of a fair and just culture. A fair and just culture allows for open communication about errors that occur within the workplace. The Principles of a Fair and Just Culture adopted at Dana-Farber Cancer Institute (DFCI) emphasize learning rather than blame and encourage open discussion and examination of mistakes. By including DFCI's principles in this Toolkit, we hope to encourage other organizations to consider adopting and implementing similar principles at their institutions.


    As you read through this Toolkit, you will find that many different positions and roles are mentioned. In this section, we list each role and briefly explain its function within the Patient Safety Rounds program. Please use this list as a guide as you read through the remaining Toolkit sections.

    Implementing Patient Safety Rounds with Staff at Your Organization

    Patient Safety Rounds with staff to obtain their input on errors and near misses is a core component of the Patient Safety Rounds program at Dana-Farber Cancer Institute (DFCI). Patient Safety Rounds with staff began in 2001 as a way of addressing the limitations associated with traditional incident reporting systems. The rounds are based on an infection control model of proactive surveillance, and over time they have proven to be an effective way to proactively identify errors and near misses.

    At DFCI, Patient Safety Rounds with staff are typically conducted on each unit by a Patient Safety Team. The team is led by DFCI's Risk Manager and includes the unit's nurse manager or charge nurse, a pharmacist, and a "Clinician Champion" or member of the staff who serves as a liaison between the team and the staff on the unit. Every member of the staff on the unit is encouraged to participate in rounds and to share insights and observations about safety issues and concerns. By design, the rounds are informal and do not place additional work on staff.

    Over the years, and with the support of executive management, Patient Safety Rounds have become an integral part of DFCI's safety program. In this section of the Toolkit, we provide a slide presentation that outlines how to develop a Patient Safety Rounds program for staff. The presentation also identifies questions that can be used to elicit staff input, discusses the development of a database to store information obtained from staff, and lists factors that are essential to the success of the program. This section also includes a document outlining qualifications for clinicians who serve in the Clinician Champion role - a role that has proven integral to obtaining the buy-in and active participation of staff on the unit.

    Involving Patients in Patient Safety Rounds

    A patient component was added to Patient Safety Rounds at Dana Farber Cancer Institute (DFCI) in 2004. Through this component, patients who are actively receiving care are interviewed about their safety concerns. The interviews were conducted by trained patients or family members who volunteer for this activity.
    Involving Patients in Patient Safety Rounds 

    Training Staff and Patients for Patient Safety Rounds

    Once Patient/Family Safety Liaisons (Liaisons) were recruited, Dana-Farber Cancer Institute (DFCI) held a Patient Safety Education Day in which we reviewed fundamental concepts of patient safety and discussed the components of the Patient Safety Rounds program.
    Training Staff and Patients for Patient Safety Rounds 

    Taxonomy for Classifying Incidents Reported During Patient Safety Rounds

    Many of the issues identified through Patient Safety Rounds cannot be easily classified using standard incident report classification schemas. In this section, we describe a taxonomy that was developed by staff at Dana-Farber Cancer Institute (DFCI) to classify incidents reported through Patient Safety Rounds and to track their occurrence over time.

    Evaluation Tools

    Patient/Family Safety Liaisons (Liaisons) and staff who participate in Patient Safety Rounds can offer useful perspectives on a Patient Safety Rounds program and help identify areas for improvement. In this section, we include surveys we used to obtain participants' feedback on each component of the Patient Safety Education Day that was held at Dana-Farber Cancer Institute (DFCI).
    Evaluation Tools 



    Medication safety in oncology: Vincristine

    Vincristine, a chemotherapy drug used in the treatment of leukemias, lymphomas, and a variety of solid tumors, may cause nerve toxicity. Despite reports for more than 30 years, "wrong route" errors occasionally occur. If delivered intrathecally (injected into the fluid-filled space around the spinal cord), rather than intravenously, the effects are usually fatal.

    The Institute for Safe Medication Practices (ISMP) conducted a survey in 2006 that showed the need for better error reduction strategies. The report included a description of correct procedures and a summary of survey results.

    Institute for Safe Medication Practices. Feb. 23, 2006. 

    The Joint Commission issued a Sentinel Event Alert in July 2005 that included a description of Dana-Farber's protocol for the proper handling and dispensing of vincristine.

    The Joint Commission. Sentinel Event Alert. July 14, 2005; Issue 34:1-3. 

    Vincristine References

    Learn more about vincristine safety in these papers, case reports, and alerts:

    1. al Fawaz IM. Fatal myeloencephalopathy due to intrathecal vincristine administration. Ann Trop Paediatr 1992; 12:339-342. Abstract 
    2. Alcaraz A, Rey C, Concha A, et al. Intrathecal vincristine: fatal myeloencephalopathy despite cerebrospinal fluid perfusion. J Toxicol Clin Toxicol 2002; 40:557-561. Abstract 
    3. Australian Council for Safety and Quality in Health Care. Vincristine can be fatal if administered by the intrathecal route. Medication Alert 2005. PDF 
    4. Bain PG, Lantos PL, Djurovic V, et al. Intrathecal vincristine: a fatal chemotherapeutic error with devastating central nervous system effects. J Neurol 1991; 238:230-234.
    5. Berwick DM. Not again! Bmj 2001; 322:247-248. Full text 
    6. Bleck TP, Jacobsen J. Prolonged survival following the inadvertent intrathecal administration of vincristine: clinical and electrophysiologic analyses. Clin Neuropharmacol 1991; 14:457-462. Abstract 
    7. Dettmeyer R, Driever F, Becker A, et al. Fatal myeloencephalopathy due to accidental intrathecal vincristin administration: a report of two cases. Forensic Sci Int 2001; 122:60-64. Abstract 
    8. Fernandez CV, Esau R, Hamilton D, et al. Intrathecal vincristine: an analysis of reasons for recurrent fatal chemotherapeutic error with recommendations for prevention. J Pediatr Hematol Oncol 1998; 20:587-590. Abstract 
    9. Gaidys WG, Dickerman JD, Walters CL, et al. Intrathecal vincristine. Report of a fatal case despite CNS washout. Cancer 1983; 52:799-801. Abstract 
    10. Gilbar PJ, Carrington CV. Preventing intrathecal administration of vincristine. Med J Aust 2004; 181:464. Full text 
    11. Michelagnoli MP, Bailey CC, Wilson I, et al. Potential salvage therapy for inadvertent intrathecal administration of vincristine. Br J Haematol 1997; 99:364-367. Abstract 
    12. Schochet SS, Jr., Lampert PW, Earle KM. Neuronal changes induced by intrathecal vincristine sulfate. J Neuropathol Exp Neurol 1968; 27:645-658.
    13. Schulmeister L. Preventing vincristine sulfate medication errors: Oncol Nurs Forum 2004; 31:E90-98. Abstract 

    For more information, contact Andrew Seger, PharmD, consultant to the Center for Patient Safety and senior reseach pharmacist at Partners' Healthcare. Andrew_Seger@dfci.harvard.edu. 

    Selected References

    Aisner J.. Overview of the changing paradigm in cancer treatment: oral chemotherapy. Am J Health Syst Pharm. 2007 May 1;64(9 Suppl 5):S4-7..

    ASHP Council on Professional Affairs.. ASHP guidelines on preventing medication errors with antineoplastic agents. Am J Health Syst Pharm. 2002 Sep 1;59(17):1648-68..

    Bartel SB. Safe practices and financial considerations in using oral chemotherapeutic agents. Am J Health Syst Pharm. 2007 May 1;64(9 Suppl 5):S8-S14..

    Bedell CH. A changing paradigm for cancer treatment: the advent of new oral chemotherapy agents. Clin J Oncol Nurs 2003;7(6 Suppl):5-9.

    Birner A. Safe administration of oral chemotherapy. Clin J Oncol Nurs 2003;7(2):158-62.

    Blough CA, Walrath JM.. Improving patient safety and communication through care rounds in a pediatric oncology outpatient clinic. J Nurs Care Qual. 2007 Apr-Jun;22(2):159-63..

    Bonnabry P, Cingria L, Ackermann M, Sadeghipour F, Bigler L, Mach N. Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. Int J Qual Health Care 2006;18(1):9-16.

    Chen CS, Seidel K, Armitage JO, et al. Safeguarding the administration of high-dose chemotherapy: a national practice survey by the American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 1997;3(6):331-40.

    Cohen MR, Anderson RW, Attilio RM, Green L, Muller RJ, Pruemer JM. Preventing medication errors in cancer chemotherapy. Am J Health Syst Pharm. 1996 Apr 1;53(7):737-46.

    Dinning C, Branowicki P, O’Neill J, et al. Chemotherapy error reduction: A multidisciplinary approach to create templated order sets. J Pediatr Oncol Nurs 2005; 22: 20-30.

    Erdlenbruch B, Lakomek M, Bjerre LM. Editorial: chemotherapy errors in oncology. Med Pediatr Oncol 2002;38(5):353-6.

    Fischer DS, Alfano S, Knobf MT, Donovan C, Beaulieu N. Improving the cancer chemotherapy use process. J Clin Oncol 1996;14(12):3148-55.

    Gandhi TK, Bartel SB, Shulman LN, et al. Medication safety in the ambulatory chemotherapy setting. Cancer 2005;104(11):2477-83.

    Goodin S. Oral chemotherapeutic agents: understanding mechanisms of action and drug interactions. Am J Health Syst Pharm. 2007 May 1;64(9 Suppl 5):S15-24.

    Hammond P, Harris AL, Das SK, Wyatt JC. Safety and decision support in oncology. Methods Inf Med 1994;33(4):371-81.

    Hollywood E, Semple D. Nursing strategies for patients on oral chemotherapy. Oncology (Williston Park) 2001;15(1 Suppl 2):37-9; discussion 40.

    Ignoffo RJ. Preventing chemotherapy errors. Am J Health Syst Pharm 1996;53(7):733.

    Johnson PE, Chambers CR, Vaida AJ. Oncology medication safety: a 3D status report 2008. J Oncol Pharm Pract. 2008 Dec;14(4):169-80.

    Kim GR, Chen AR, Arceci RJ, et al. Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Arch Pediatr Adolesc Med 2006;160(5):495-8.

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