Transcript No Slide Title

Dana-Farber Cancer Institute’s
Patient Safety Journey:
Lessons Learned
III Simposio Internacional de Seguridad del
Paciente
Centro Medico Imbanaco
Cali, Colombia
Saul N. Weingart, MD, PhD
Dana-Farber Cancer Institute & Harvard Medical School
Boston, Massachusetts, USA
1
DANA-FARBER ADMITS DRUG OVERDOSE
CAUSED DEATH OF GLOBE COLUMNIST,
DAMAGE TO SECOND WOMAN
3/23/1995
When 39-year-old Betsy A. Lehman died suddenly last Dec. 3 at Boston's
Dana-Farber Cancer Institute, near the end of a grueling three-month treatment
for breast cancer, it seemed a tragic reminder of the risks and limits of highstakes cancer care. In fact, it was something very different. The death of
Lehman, a Boston Globe health columnist, was due to a horrendous mistake: a
massive overdose of a powerful anticancer drug that ravaged her heart, causing
it to fail suddenly….
Betsy Lehman Legacy
• 1994: 5-fold chemotherapy overdose
affecting Betsy Lehman and Maureen
Bateman
• Discovered on protocol review
• Critical media attention and regulatory
review
3
Error in oncology:
A perfect storm?
•
•
•
•
•
•
Aggressive disease
Toxic therapies, many novel
Vulnerable patients
Adverse event vs. clinical end point?
Complex regimens and protocols
Interdisciplinary and interprofessional care teams
• Care distributed over time and place
• Production pressure and fiscal
constraints
4
DFCI Patient Safety Efforts
• Relentless surveillance
 Including non-punitive reporting and disclosure
Hazard Surveillance
Event reporting
• Staff safety reports
• Pharmacy
interventions
• RCAs, FMEAs
Environmental scanning
• Literature reviews
• Meetings/memberships
• Patient safety alerts
Executive walk rounds
External performance
measurement
• ISMP
• RMF risk assessment
• Malpractice claims
analysis
• Leapfrog survey
Research
Hazard
Surveillance
Patient reports
• Volunteer rounders
• Patient online
reporting
• Press Ganey surveys
• Complaints
Internal performance
measurement
• Department reports
• Regulatory readiness
• Safety culture survey
• Focus groups
• IRB/DSMC
Clinician-level
monitoring
• OPPE/FPPE
• Credentialing
Slide from rL
7
Pharmacy Interventions
Intervention Categories
Miscellaneous,
25 (11%)
Near Miss
43 (19%)
Info/Clarification
42 (19%)
Clinical
Recommendation
Protocol Driven
33 (15%)
83 (36%)
Total Interventions reported: 226
Safety Culture Survey Results
Positively Worded Question
Category
2009
%
Agree
2010
%
Agree
Diff
2010
Benchmark
When a lot of work needs to be done quickly, we work together
as a team to get the work done.
Teamwork within
units
92
89
-3
85
Supervisor
expectations &
actions
86
81
-6
76
The actions of hospital management show that patient safety is
a top priority.
Management
support for
patient safety
90
88
-2
73
Mistakes have led to positive changes here.
Organizational
learningimprovement
88
82
-6
63
Overall
perceptions
63
64
1
62
Staffing
40
31
-9
54
Teamwork within
units
84
80
-4
77
Management
support for
patient safety
80
83
3
79
We are given feedback about changes put into place based on
event reports.
Feedback about
error
56
53
-3
55
We are informed about errors that happen on this unit or clinic.
Feedback about
error
49
50
1
62
My supervisor or manager seriously considers staff
suggestions for improving patient safety.
Patient safety is never sacrificed to get more work done.
We have enough staff to handle the workload.
In this unit, people treat each other with respect.
Hospital management provides a work climate that promotes
patient safety.
DFCI Patient Safety Efforts
• Relentless surveillance
• Ongoing information technology
(IT) investments




Chemotherapy order-entry
Electronic medical record
Bar coding
Smart pumps
Oral Chemotherapy Risks
• Adherence problematic in high-risk
populations
 Partridge et al., JNCI 2002
• Administration errors common among ALL
families
 Taylor et al., Cancer 2006
• Routine safety precautions not used at 1/3 of
US cancer centers; serious AE in past year at
1/4.
 Weingart et al., BMJ 2007
14
15
Calculator for dose
reduction
Users have option of choosing calculated doses
based on Weight or BSA, or a fixed dose option.
Height and Weight
pulled from vital signs
flowsheet
1) Diagnosis from LMR
or pick list
2) Indication is pick list
3) Both can be
suppressed by nononcology users
16 16
DFCI Patient Safety Efforts
• Relentless surveillance
• Ongoing IT investments
• Patient/family involvement
 Incident reporting
 Medication reconciliation
 Teamwork training
Medication Reconciliation
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Medication Reconciliation
Protocol
Collect &
Evaluate
Providers or Pharmacists
Update EMR
Patients
Update
Med Lists
CAs
Prep
Charts
CAs
Provide
Med Lists
Medication Reconciliation Monthly Totals
2500
2000
1500
1000
500
Implement
Sustain
Develop
'07
M
ar
M
ay
Ju
ly
'0
7
Se
pt
No
v
Ja
n
'08
M
ar
ch
Ja
n
No
v
Ju
l '0
6
Se
pt
ay
M
ar
M
'06
Ja
n
'0
5
0
No
v
Medication sheets reconciled
November 2005 - March 2008
Sheets reconciled
95% CI
Teamwork Training for Patients
High-Performance Teamwork
Training
• Promising application in ICU, OR, ER,
L&D, other?
• Key principles:




Appropriate assertiveness
Briefing
Close-loop communication
Situational awareness
25
Revised approach
• Campaign rather than education or
research
• Focus on hazards rather than skills
 Wrong chemotherapy, last-minute change,
hand hygiene
• Bringing messages to the patient
• Empowerment without obligation
 “You CAN… check, ask, notify”
In 2012, we proudly celebrate
Adult Council for 14 years
Pediatric Council for 11 years
DFCI Patient Safety Efforts
•
•
•
•
Relentless surveillance
Ongoing IT investments
Patient/family involvement
Research and development
Research and Development
34
Amb. oncology medication errors
• Prospective cohort study of outpatient infusion
units at one cancer center in 2000.
• 10,112 medication orders for 1,380 adults and
226 children were reviewed.
• The medication order error rate was 3%.
 2/3 had the potential to cause harm (none did, most
intercepted by pharmacist or nurse).
 1/3 related to chemotherapy.
Gandhi et al., Cancer 2005
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Chemotherapy order errors
25%
20%
15%
10%
5%
0%
Missed
dose
Failure to
Missing
d/c order for parameters
held tmt
Gandhi et al., Cancer 2005
Failure to
use etemplate
Teamwork Training for Staff
“Change Order” Guidelines
Telephone/Page When…
•Change in treatment plan
Hold chemotherapy- orders must be promptly d/c’d in COE
New chemotherapy regimen is started
New chemotherapy drug is added
Does not include reduction in dose if COE contains specific reason(s) for reduction
•New chemotherapy patients
•Disease progression
•Restart of therapy after significant break
•Additional non chemo orders have been entered that day
( i.e. blood transfusions, electrolyte replacement)
Guidelines:
•Telephone callback is not required once orders are entered
Email When…
•Use DFCI D10 Charge Nurse for non-urgent needs (greater than 24 hour response time)
Charge nurse will deliver message to treating nurse
Case
Patient arrives for chemotherapy. MD writes to
give chemotherapy regardless of counts. ANC
returns at 300, well below standard parameters.
Pharmacist is uncomfortable and concerned for
patient safety so calls MD. MD angrily says to
pharmacist, “I said to treat regardless of counts.”
39
Conflict Video
Conflict Video
40
DFCI Patient Safety Efforts
•
•
•
•
•
Relentless surveillance
Ongoing IT investments
Patient/family involvement
Research and development
Trustee engagement
Vulnerabilities
Annual
• Production pressure
• Oral/IV chemotherapy
• Complex protocols
• Team communication
re: patient status &
handoffs
efenses
Risk DAssessment
• Offload & redistribute
clinical volume
• IT improvements
(LMR, COE, bar
coding, eMAR,
Gateway)
• Lack of process
improvement
infrastructure
• Safety culture and
oversight
• Satellite sites
• QI/PI skill
development
Hazards
Defenses
• Teamwork training
43
Dana-Farber Cancer Institute
Patient Safety Timeline
Leapfrog Group survey results
Conditional Joint Commission
posted
IHI Mentor hospital
accreditation
Joint Commission accreditation with
commendation
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Next
Chemo
ADEs
Remediation plan
Board level quality committee revitalized
Hospital and community partnerships
Adult PFAC
Sentinel Event Policy
Medical Error Disclosure Policy
Disclosure
Pedi PFAC
Medical Executive Committee engagement
Patient Safety Committee
Center for Patient Safety
Fair and Just Culture policy
Adopt JCAHO Patient Safety Goals
MHA Patients First
Baldrige assessment
Root cause analysis
FMEA
Pharmacy interventions reported
Patient/family volunteer rounding
RR
FMEaPatient safety rounds
Hand hygiene monitoring
Electronic safety reporting
Extra checks and approvals for high-dose chemo
Separate look-alike, sound-alike drugs in pharmacy
Specialized training for nurses in new chemo procedures
Increased supervision of trainees
Patient intervention program in pharmacy records and reports errors and trends
COE startup (Standardize protocols; Drug/allergy initiative; Chemo flow sheets)
COE major expansion
Pediatric templates
Pediatric daily and course dosage checking
LMR
Falls task force
PEAR
Percipio
Bar code wristband pilot
Bar code system-wide
Inpatient eMAR
Key
Pediatric Powerchart
Culture and infractructure
Medication reconciliation
Analysis of risk
Teamwork training for
Surveillance for hazards
Patient gateway
Improvement initiatives
Anticoagulation
Oral chemotherapy
improvement
Outpatient eMAR
44
Outpatient medication errors reaching the patient and requiring monitoring or
causing harm, 1997 to 2004. Dosage data captured from pharmacy system.
Harm data captured from DFCI incident reporting systems (USP Error Outcome
Category D-I). Source: Conway et al., ASCO Education Book 2006.
45
Current priorities
• Reduce infection risk for patients and staff
• Enhance safety of high-risk therapies (medications
and radiation) across the network
• Improve teamwork and communication
• Enhance quality measurement and reporting
• Improve operational efficiencies through the
dissemination of performance improvement
techniques
• Enhance clinician engagement in performance
improvement and peer review activities
Thank you
“Say…What’s a mountain goat doing
way up here in a cloud bank?”