Multidisciplinary approaches to reducing error and risk in a patient care setting.
In 1995, a medication error at Boston's Dana-Farber Cancer Institute (DFCI) that received intense media scrutiny, transformed the Institute in many ways. Primarily, patient safety became a major priority that led to Institute-wide organizational learning. As a result, DFCI emerged as a national leader in the patient safety movement. A key factor believed to have contributed to this effort was the use of a multidisciplinary team approach to identifying and preventing errors, with the patient and family members as an integral part of the team. In addition to teamwork, other activities included implementing a new chemotherapy order entry system, transforming the culture to a non-punitive one where staff are encouraged to openly discuss errors and safety issues, and introducing a root cause analysis process for error/near miss investigations. Several guiding principles served as the foundation for the efforts including: 1) systems, not individuals, must be the focus of safety initiatives; 2) organizations must create a non-punitive culture; 3) changes must be hard-wired into systems; and 4) multidisciplinary participation, including patients and families, is critical to success.
Connor
Maureen
M
maureen_connor@dfci.harvard.edu
Ponte
Patricia Reid
PR
Conway
James
J
D001900:Boston; D002173:Cancer Care Facilities / Q000458:organization & administration*; D003661:Decision Support Techniques; D030881:Disclosure; D006801:Humans; D007400:Interprofessional Relations; D019300:Medical Errors / Q000517:prevention & control*; D015279:Organizational Culture; D010348:Patient Care Team / Q000458:organization & administration*; D010358:Patient Participation; D011368:Professional-Family Relations; D012308:Risk Management / Q000458:organization & administration*; D013597:Systems Analysis