Multidisciplinary approaches to reducing error and risk in a patient care setting

When Dana-Farber Cancer Institute (DFCI) of Boston became the setting of a highly publicized drug overdose incident in 1995, nurses, administrators, physicians, clinical and other staff, patients and family members, and trustees were all affected by the event on some level. ‘‘How could this have happened?’’ was a question on the minds of all parties. Soon it became clear that finding the answer was not enough. In addition to the internal and external investigations, DFCI committed itself to becoming a model of patient safety and error prevention. In the past seven years, DFCI has transformed an adverse event into a catalyst for reaching new levels of excellence in reducing errors and potential errors throughout the Institute. This has been accomplished not only through the multidisciplinary efforts of nursing, pharmacy, physician, administrative, and other clinical staff but also through innovative involvement of patients, families, and trustees. The work is ongoing and never finished but has produced several processes and outcomes that could be beneficial for others refining patient and staff safety and service programs.