Annual Report

ANNUAL REPORT 2005 Center for Patient Safety Dana-Farber Cancer Institute Center for Patient Safety Dana-Farber Cancer Institute Annual Report, 2005 Patient safety emerged as a public health issue with the 1999 publication of To Err is Human by the Institute of Medicine. The report brought nationwide attention to the problem of medical error and patient safety. Patient safety is at the core of the Institute’s mission and vision, and Dana-Farber Cancer Institute has been a leader in advancing safe practices and reducing the risk of medical error. The Center for Patient Safety, created in 2003, brings together clinicians, administrative staff, researchers, patients, and families to promote research, clinical improvement, and education at the Institute and beyond. The Center for Patient Safety was conceived by Dana-Farber President Edward J. Benz, Jr., MD, and former Executive Vice President and COO James Conway as a vehicle within the Institute to develop, study, and bring about improvements in patient safety. Barbara Bierer, MD, served as the first director. The Center was reorganized in Fall 2004 with the recruitment of Saul N. Weingart, MD, PhD, as director of the Center and Vice President for Patient Safety. This report describes the activities of the Center for Patient Safety, its staff, and affiliates in 2004-5. It reports on both completed and ongoing initiatives. This work rests on the foundation of a decade of accomplishment by extraordinary staff and clinicians at Dana-Farber Cancer Institute in patient safety, risk management, quality improvement, information systems, pharmacy, and clinical care. Mission Statement To shape the activities and organization of the Center for Patient Safety, staff searched the literature and the Internet and identified a variety of patient safety centers across the nation. Many were funded by government entities or grants, or represented institutional offices that sought to improve quality, safety, and regulatory compliance. Absent a replicable model, Center staff embraced a vision of a group that spanned clinical practice and research, using the Institute as a laboratory for three goals: research, education, and improvement. The Center adopted the following mission statement after review by the Institute’s Patient Safety Committee and board level Quality Improvement/Risk Management Committee: The mission of the Center for Patient Safety is to reduce the burden of medical injury in cancer care. The Center serves as a laboratory for innovation, challenging the boundaries of education, scholarship, and quality improvement in patient safety. Grounded in research and interdisciplinary collaboration, the Center has a special interest in understanding the role that patients and families can play, together with clinicians, in preventing medical errors. 2 Organization and Staffing The Center includes a small working group of professional staff and a network of members from throughout the Institute. It was conceived as a broad umbrella, welcoming those who sought to teach, learn, or participate. The Center also has a small oversight group including the Chief Medical Officer, chair of Population Sciences, Vice President of Quality Improvement, and Vice President for Patient Safety. Activities are reported regularly to the Institute’s Patient Safety Committee, Medical Staff Executive Committee, and the board Quality Improvement/Risk Management Committee. The staff is an interdisciplinary group with expertise in research, quality improvement, and project management. Recruited in 2004-5, the staff includes 2 physicians, 2 nurse program managers, a research pharmacist, an educator, and an administrative assistant. Short biographies are appended. Priorities The Center identified four priority areas:     Medication safety Diagnostic errors Infection control High-performance teamwork Medication Safety Medication safety has been a key priority of the Institute since its inception, with redoubled interest following the overdose cases of 1994. During the past decade, staff introduced pharmacy safe practices; the development, introduction, and refinement of chemotherapy order entry systems; and the use of an integrated electronic medical record. A November 30, 2004 Boston Globe article on the 10-year anniversary of the Betsy Lehman and Maureen Bateman deaths recognized the Institute’s advances. Demonstrating both its results and a commitment to transparency, the Institute released medical error data showing less than 1 harmful error per 10,000 chemotherapy doses administered. 3 Errors reaching patients/10,000 medications dispensed 4 3.5 3 2.5 2 1.5 1 0.5 0 1997 1998 1999 2000 2001 2002 2003 2004 Total errors Monitoring or temporary harm Permanent harm Ongoing medication safety efforts continue through the Institute’s Pharmacy and Therapeutics Committee and Patient Safety Committees, through the Department of Quality Improvement/Risk Management, and via Information Systems initiatives to introduce the electronic medication administration record and bar-coding technology in the adult inpatient and outpatient settings. The Center took the lead on two medication safety initiatives in 2005. The first was an effort to improve the safety of inpatient medication use on the adult oncology service at Dana-Farber/Brigham and Women’s Cancer Center. After identifying a deficiency in the use of unsafe abbreviations in hand-written communication during our March 2005 JCAHO audit, Center staff led an interdisciplinary team to implement several improvements (Table 1). Using JCAHO measurement methods, DF/BWCC attained the goal of less than 10% use of unapproved abbreviations for all orders, progress notes, and medication administration records. 4 Table 1: Improvements Made to Decrease Use of Unapproved Abbreviations 1. Signs showing the unapproved abbreviations were posted prominently on all BWH oncology units and by most workstations. 2. New progress note forms were approved and distributed. They list the unapproved abbreviations at the bottom of each page. 3. Medical Records confirmed that the dictation service for discharge summaries makes automatic replacement of unapproved abbreviations with approved equivalents. They also implemented a similar practice for admission and consult notes. 4. The oncology service Nurse Manager and Medical Director at BWH and Vice President for Patient Safety at DFCI sent an email message to the entire clinical team, including attending physicians, nurses, house officers, physician assistants and facilitators on the oncology units, underlining the importance of adherence to the unapproved abbreviation policy. Follow-up meetings occurred with nursing staff and unit facilitators. 5. Vice President for Patient Safety met with BWH Director of the Medicine Residency Training to ensure his support for the program. The 2005 housestaff handbook and pocket guide included information about unapproved abbreviations. Attending physicians on the oncology service were asked to remind housestaff on a regular basis about the abbreviation initiative. 6. Weekly chart audits of the medication administration record and inpatient medical record of all patients on the DFCI-licensed pods were performed for eight months. Personalized email messages were sent to staff members who wrote the unapproved abbreviations, along with educational materials. 5 Unapproved Abbreviations 35 30 25 Percent 20 15 10 5 0 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Handwritten Handwritten and Typed The second medication safety initiative was to improve medication safety in adult ambulatory care through medication reconciliation. Medication reconciliation, defined as the comparison and correction of patients’ medication lists at transitions in care, was introduced as a 2006 JCAHO National Patient Safety goal. It was also included in the Institute for Healthcare Improvement’s 100K Lives Campaign. The Dana-Farber initiatives had two major components. The first dealt with new patients and the second addressed established patients. The Center developed a medication safety information brochure. It contains a set of recommendations for patients that contribute to safe medication use, and includes a form to list current medications and health information at the patient’s initial visit. The brochures, available in English and Spanish, have been included in the materials mailed to new adult patients since September 2005. A pediatric version is distributed in the Jimmy Fund Clinic. The content was developed scientifically, based on a review of patient safety recommendations from Internet and print publications of 20 professional groups, government agencies, patient safety coalitions, health plans, and commercial entities. Center staff also led a DFCI initiative to create a model medication reconciliation program in ambulatory oncology. Working closely with clinic and pharmacy staff, the approach relies on clinic assistants to distribute a copy of the patient’s medication and allergy list to returning patients for review. The patient-updated forms are given to the physician or nurse practitioner and then updated electronically. Pilot tests with 338 patients showed that 4 out of 5 patients had errors in their medication lists and that most errors were updated following reconciliation. An unrestricted grant to the Center for Patient Safety from Blue Cross/Blue Shield will support a part-time pharmacist to facilitate entry of corrected medication information. The medication reconciliation program was implemented Institute-wide in November 2005. 6 Diagnostic Errors Missed and delayed colon and breast cancer diagnoses are a leading cause of medical malpractice claims in the Harvard system and nationally. The Center received a $104,000 grant from the Risk Management Foundation to study missed and delayed breast cancer diagnoses in collaboration with the researchers at Brigham and Women’s Hospital, Harvard School of Public Health, and Harvard Vanguard Medical Associates. This work is scheduled to be completed in 2005-06. In oncology care, timely diagnosis and management of symptoms related to patients’ cancer and treatment is another challenge. In order to understand this phenomenon, Center staff obtained data about pain screening for patients who were seen at DFCI in 2004. Among more than 170,000 visits to the Institute, clinic assistants screened 96% for pain-related symptoms. Center staff, led by Angela Cleary, identified units with low screening rates for quality improvement initiatives. On one unit, screening rates increased from 25% to 95% following the intervention. Pain Score Documentation in Electronic Record for GYN Oncology Clinic Percent documented 100 80 60 40 20 0 8/12/2005 8/26/2005 9/9/2005 9/23/2005 10/7/2005 10/21/2005 Week ending Working with the Palliative Care Group and the Interdisciplinary Pain Management Group, staff developed a chart review tool to examine clinicians’ pain assessment, diagnosis, and treatment plans. Chart audits of patients with high pain scores (greater than 7/10 in severity) in Breast, Gastrointestinal, and Gynecologic Oncology identified problems with documentation in each area. For example, there was no evidence of a pain assessment in 28% of clinician notes, and 36% of patients with high pain scores had no documented treatment plan. Additional studies are underway in order to understand the quality of pain screen information, patient satisfaction with pain care, and mechanisms to communicate critical pain information to the responsible clinician. 7 Infection Control Hand hygiene is one of the most important ways to prevent hospital-acquired infections. However, observational studies show that hand hygiene compliance is discouragingly low (20-40%) in most hospitals. Infection Control leaders at DFCI have supported safe practices for many years. As a result, hand hygiene compliance on the DF/BWCC adult inpatient service meets or exceeds national benchmarks, with rates of 80-85%. In 2004, the Center for Patient Safety began to support the Infection Control program by performing direct observations on the DF/BWCC inpatient service. In addition, Center staff began a project to examine hand hygiene practices in ambulatory oncology care. This is one of the first efforts to systematically monitor hand hygiene in outpatient care. Led by Laurinda Morway, staff searched the literature and interviewed leaders at hospital systems in Minnesota and Pennsylvania that had implemented successful hand hygiene initiatives in hospitals. Starting in April 2005, staff began to monitor hand hygiene adherence on two adult ambulatory infusions units at DF/BWCC. Performance rates were reported to local managers. Within 4 months, both units had attained national benchmark rates hand disinfection in inpatient units. Hand Hygiene Compliance DFCI Adult Infusion Units 100 90 80 70 60 50 40 30 20 10 0 56 83 70 67 90 80 81 90 82 80 86 80 79 Unit A Unit B Goal 87 86 Percent March April May June July Aug Sept Oct Hand hygiene clinician “champions” were recruited on each unit and a series of improvement projects were identified for 2005-6. Center staff surveyed hand hygiene in the Jimmy Fund Clinic as well, and offered clinic leaders best practice recommendations. 8 High-Performance Teamwork Center staff began in 2004-5 to develop an agenda for improving communication, transitions of care, and teamwork in oncology care. Studies of high reliability organizations suggest that teamwork skills may be adapted from the cockpit to clinical care environments. The Center, together with ambulatory medical and nursing leadership, invited Benjamin Sachs, Chair of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center, to describe his department’s work in this area to DFCI clinical leaders. Daniel Gorman, Nurse Manager on Dana 10, organized a text pager pilot to facilitate rapid communication between clinicians and infusion room nurses. Center staff analyzed the results of the pager initiative, and found relatively low volume but high clinical content on the pages. The system was expanded in late 2005. Additional work on Dana 11 will involve the creation of small work teams to enhance breast cancer care. The teams will introduce pre- and post-practice briefings, a technique that is used to identify and mitigate teamwork failures in other settings. Additional work, under the leadership of Ann Michelini, aims to improve handoffs across institutions and signoffs between providers. Ms. Michelini identified best practices in the discharge transition and is currently supporting work in pediatric oncology to streamline that process. She also works with nursing staff on best practices in clinician sign-outs. Research and Education Center staff participated in a variety of patient safety research and education programs in 2005. Dr. Weingart joined a project led by Barbara Bierer, MD, BWH Senior VP for Research, and Patricia Reid Ponte, RN, DFCI’s Chief of Nursing and Patient Care Services in a study entitled, “The Role of Patient and Clinician Champions as Safety Advocates in Adult Ambulatory Multidisciplinary Practice Settings.” This study measured the impact of clinician and patient safety champions on the Patient Safety Rounds program at DFCI. It was funded by grants from the Commonwealth Fund and the National Patient Safety Foundation. The Center for Patient Safety co-sponsored a colloquium that featured early results from the project on June 6, 2005, and welcomed the Center's first Visiting Professors: Susan Grant, RN, MS, Chief Nursing Officer, University of Washington Medical Center, Seattle, WA; Floyd J. Fowler, Jr., PhD, Senior Research Fellow at the Center for Survey Research, UMass Boston, Boston, MA; and Susan Edgman-Levitan, PA, Executive Director of the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital, Boston, MA. The study and its preliminary findings were presented at the 2nd International Conference on Family-Centered Care in San Francisco, CA, in February 2005, the 7th Annual National Patient Safety Foundation 9 Congress in Orlando, FL, in May 2005, the American Organization of Nurse Executives 38th Annual Meeting and Exposition in Chicago, IL, in April 2005, and the American Society of Healthcare Risk Management Annual Conference in San Antonio, TX, in October 2005. Dr. Weingart, with colleagues from Beth Israel Deaconess Medical Center, completed a series of studies to examine the role that patients play in identifying medical errors and injuries. In a study published in the International Journal for Quality in Health Care, investigators found that 11% of patients recognized an error affecting their care, and that 29% of nurses on the study unit said that a patient or family member prevented an accident. In subsequent studies, Dr. Weingart and colleagues collected incident reports from medical inpatients during their hospitalizations. Eight percent of patients experienced an adverse event--an injury due to care. Surprisingly, none of these incidents was reported or recorded in the hospital’s incident reporting system. Additionally, more than half of patients in this cohort identified problems with the service quality associated with the admission. Additional studies to examine the relationship between injuries and patients’ reports of poor service are underway. Dr. Weingart and colleagues, including former DFCI EVP and COO James Conway, also published studies of physician leadership in patient safety, outlining challenges for health executives and drawing lessons from the Dana-Farber experience. In addition, a Risk Management Foundation-funded study led by DFCI pharmacy director Sylvia Bartel and Brigham and Women’s Hospital’s Tejal Gandhi published in 2005 analyzed medication errors among DFCI adult and pediatric oncology patients. Using intensive chart review methods, investigators found high but expected rates of treatment-related symptoms but a relatively low medication error rate of 3%. Center staff members lecture widely about patient safety. James Conway leads a course on quality improvement for the Executive Program of the Harvard School of Public Health. Conway and Saul Weingart are faculty of the Health Forum Patient Safety Leadership Fellowship. Dr. Weingart, with David Bates from Brigham and Women’s Hospital, and Hans Kim from Beth Israel Deaconess Medical Center, are course directors for The Patient Safety Imperative, a continuing education course offered through Harvard Medical School that attracts an international audience of physicians and other health professionals. Dr. Weingart is leading a grant-funded curriculum development initiative in patient safety for hospitalist faculty at Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Boston Children’s Hospital, and Massachusetts General Hospital. Goals for 2006 With resources and staffing in place, the DFCI Center for Patient Safety will continue to advance its priority initiatives. We will facilitate implementation of the 10 medication reconciliation initiative, and complete the RMF-funded study of missed and delayed cancer diagnoses. Staff will create cutting-edge research and improvement initiatives in pain and symptom management, and in communication and highperformance teamwork. The Center will seek external resources and national partners in order to leverage these efforts. The Center will formalize its membership and advisory structure in the coming year. It will also roll out new patient safety Intranet and Internet Web Sites, making information about the activities of the Center, its work products, and other patient safety resources widely accessible. Center staff will support Information Systems Department innovations in safety reporting and bar coding. The reporting system, rL Solutions Risk Monitor Pro, is expected to go live at DFCI in early spring 2006. Staff will also bring to fruition a patient safety measurement initiative, creating dashboards to allow leaders, patients, and frontline staff to track the organizations’ performance with respect to regulatory requirements and internal safety metrics. The Center will continue to work with our patients and on behalf of our patients to create the world standard for safe cancer care. 11 Center for Patient Safety Staff Saul Weingart, MD, PhD Laurinda Morway, EdM Angela Cleary, RN, MSN Ann Michelini, RN, MSN Andrew Seger, PharmD Daniela Brouillard Mark Saadeh, MD Saul N. Weingart, MD, PhD Dr. Weingart serves Vice President for Patient Safety and Director of the Center for Patient Safety at Dana-Farber Cancer Institute. He is Assistant Professor of Medicine at Harvard Medical School and practices primary care internal medicine at Beth Israel Deaconess Medical Center. Prior to joining DFCI in 2004, Dr. Weingart was Director of Patient Safety in the Division of General Medicine. He also served as Medical Director of Patient Safety for CareGroup Healthcare System. He holds a doctorate in public policy from Harvard’s John F. Kennedy School of Government and an MD degree from the University of Rochester. He completed an internal medicine residency and general medicine fellowship at Beth Israel Deaconess Medical Center and Harvard Medical School. Dr. Weingart’s research interests include the development of voluntary reporting systems for medical errors, patient and clinician participation in the prevention of adverse events in health care, and executive leadership in patient safety. Laurinda Morway, EdM Laurinda Morway is Research Resource Administrator at the Center. She received a Master in Education degree and Certificate of Advanced Study from the Harvard Graduate School of Education (HGSE), and a BA from Connecticut College. She was a member of an HGSE research team that investigated leadership and social responsibility in the professions. Before coming to Dana-Farber in 2004, she was research assistant to Lucian Leape at the Harvard School of Public Health for five years. At the Center, she works on a variety of research, education, communication, and clinical improvement projects. Angela Cleary, RN, MSN Angela Cleary is a Program Manager at the Center. She received her Bachelor degree from the University of Wisconsin at Madison and her Master degree from Northeastern 12 University. She worked as a staff nurse for seven years in medical/surgical, oncology and bone marrow transplant. She served as a traveling nurse for Newton-Wellesley Hospital, Massachusetts General Hospital, and Brigham and Women's Hospital. Since leaving staff nursing, she has worked in research, education, and the insurance sector. She participated in medication error studies in oncology at Dana-Farber Cancer Institute before joining the Center in 2005. She works on initiatives in medication safety and performance measurement. Ann Michelini, RN, MSN Ann Michelini is a program manager at the Center for Patient Safety. She worked as a business analyst at Empire Blue Cross and Blue Shield in New York City. After receiving Bachelor of Nursing and Master of Science in Nursing Administration degrees from the University of Pennsylvania, she worked as a staff nurse in thoracic oncology at Memorial Sloan Kettering Cancer Center. She worked at Dana-Farber as a clinical research nurse in gastrointestinal oncology before joining the Center in 2005. She is developing initiatives on team training and patient safety in clinical research. Andrew C. Seger, PharmD Andrew Seger is a consultant pharmacist for the CPS. He received his BS and PharmD degrees from the Massachusetts College of Pharmacy. Working as staff pharmacist, he served as a consultant and research pharmacist at the Institute for Safe Medication Practices, the Risk Management Foundation of the Harvard Medical Institutions, The Meyers Primary Care Institute, and Brigham and Women’s Hospital. He has assisted in the design, development and implementation of computerized decision support for an ambulatory electronic medical record. At Dana-Farber, he helped to develop and implement medication reconciliation systems in ambulatory clinics and standard best practices for administration of chemotherapy. Daniela Brouillard Before becoming Administrative Specialist at the Center for Patient Safety, Daniela Brouillard worked as an Account Coordinator at Euro RSCG Life Managed Edge, a managed care consulting firm in New York City. She also has several years’ experience working in medical education and not-for-profit organizations. She received her BA from the New School for Social Research in New York. At the Center for Patient Safety, she is involved in hand hygiene, oral chemotherapy safety, and medication reconciliation initiatives. 13 Mark Saadeh, MD Mark Saadeh is a Clinical Research Coordinator at the Center. He received his BA degree from Harvard College, and graduated from Harvard Medical School in 2005. He spent time during medical school volunteering in inner city Boston, and conducted research on psychopharmacology, medical education technology, and the spiritual and existential needs of oncology patients. At the Center, he is involved in a project to prevent missed or delayed breast cancer diagnoses. 14 Center for Patient Safety Publications, 2004-5 1. Conway JB, Weingart SN. Organizational change in the face of highly public errors: I. The Dana-Farber Cancer Institute experience [commentary]. Web M&M, US Agency for Healthcare Research and Quality, May 2005. Available at: http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=3. Accessed May 11, 2005. 2. Gandhi TK, Weingart SN, Seger AC, et al. Outpatient prescribing errors and the impact of computerized prescribing. J Gen Intern Med 2005;20: 837-841. 3. Gandhi, TK, Bartel SB, Shulman LN, et al. Medication safety in the ambulatory chemotherapy setting. Cancer 2005; 104:2477-83. 4. Huang GC, Smith CC, Gordon CE, Feller-Kopman DJ, Davis RB, Phillips RS, Weingart SN. Beyond the comfort zone: residents assess their comfort performing inpatient procedures. Am J Med, in press. 5. Weingart SN, Page D. Implications for practice: challenges for health care leaders in fostering patient safety. Qual Safety Health Care 2004; 13 (suppl 2): ii52-56. 6. Weingart SN, Toth M, Eneman J, et al. Lessons from a patient partnership intervention to prevent adverse drug events. Int J Qual Health Care 2004; 16: 499-506. 7. Weingart SN. Beyond Babel: prospects for a universal patient safety taxonomy [editorial]. Int J Qual Health Care 2005; 17:93-4. 8. Weingart SN, Conway JB. Promoting an organizational infrastructure for patient safety. Ch. 2 in From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd ed. Oak Brook, IL: Joint Commission Resources, 2005. 9. Weingart SN, Pagovich O, Sands DZ, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med 2005; 20:830-36. 10. Weingart SN, Gandhi TK, Seger AC, et al. Patient-reported medication symptoms in primary care. Arch Intern Med 2005; 165:234-40. 11. Weingart SN, Pagovich O, Sands DZ, et al. Patient-reported service quality on a medicine unit. Int J Qual Health Care 2005; Nov [epub ahead of print] 12. Weingart SN, Rind D, Tofias Z, Sands DZ. Who uses the patient Internet portal? The PatientSite experience. J Am Med Info Assoc, in press. 15