Patient Safety Reporting Form

Patient safety is a top priority at Dana-Farber. While your care team takes responsibility for ensuring your safe care, we’ve found that patients and their families can teach us things that we didn’t know. This helps us create the safest possible care.

Safest Care is a system designed to help us hear your voice.

You may have ideas about things we can do to improve patient safety. If you have experienced something that seemed risky or caused you harm, or if you noticed something that you think is unsafe, we want to hear about it.

After you talk with your provider or other caregiver and make sure that any problems are addressed, we hope you will take a few minutes to let us know what happened. This information is confidential.

If you spoke to a staff member, that person may have filed a report in the hospital Safety Reporting System. Why should you submit another report?

  • You may have a different viewpoint about what happened.
  • You may have noticed other details.
  • You may have suggestions for safety improvements.

A patient or family member, friend, or other advocate can submit a report. Patient safety experts at Dana-Farber review reports weekly. We encourage you to include your name and contact information, so that we may reach out to you if we have any questions.

Patient Safety Reporting Form
Do you have comments or suggestions for improvement in the safety of care at Dana-Farber?
 
If you experienced a problem with patient safety that you want to tell us about, please continue.
When did the event occur? (Month, day, year)
 
At which Dana-Farber facility did the event occur?
 
Where in the hospital did the event take place? (For example, Infusion – Yawkey 6, Radiology, or Exam – Yawkey 9)
 
What happened? Please describe. 
 
What impact, if any, did the event have for the patient? (For example, an unplanned return to the hospital; additional lab tests; harm).
 
Did you tell a staff member about the event?
 
If no, why didn't you tell someone about it?
 
If someone else discovered the event, please state who — for example, a nurse:
 
If you did tell a staff member, were your concerns or questions answered?
 
What do you think could have prevented the event or prevent similar events in the future?
 
This form was filled out:
  By the patient
  By a relative or friend
  With help from staff
If filled out with help from staff, please specify — for example, nurse or doctor:
 
Patient gender:
 
Patient age: 
Optional contact information
Would you like to talk to someone about the event?
 
May we contact you about your report if we need more information?
 
If you selected "Yes" to either question, please let us know how to contact you. This will be confidential. You will be contacted within seven business days.
Name:
Patient name (if different):
Phone:
Best times to call:
 
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