Key Learning from the Dana-Farber Cancer Institute's 10-Year Patient Safety Journey

Overview: The tragic chemotherapy overdoses to Betsy Lehman and Maureen Bateman, which were discovered at the Dana-Farber Cancer Institute (DFCI) in February 1995, are well known to the cancer community and the public. With 2004 to 2005 marking the 10-year anniversary of these events, DFCI leadership assessed its patient safety learning. The six most critical elements of learning were as follows: the responsibility and power of all leadership to drive patient safety after the overdose and thereafter; the need for relentless vigilance every day to safety, risk, error, near miss, and harm at all levels of the organization by all staff; the responsibility of addressing the multiple victims of error, including the patient, the family, and the staff; the power of partnership in patient-centered and family-centered care; the crucial role that the design of systems and application of technology play in support of safe practice by excellent, not perfect, staff; and the synergy of interdisciplinary practice and team work. The organization remains excellent (not perfect) and vigilant in closing the gap through ongoing priorities and by reassessment of how the journey could be enhanced.