I nearly fainted at the end, and it had taken a little more than an hour — at least 10 minutes longer than I had ever required to run that distance. I thought I was just run down from being a busy mother of three, so I was shocked to learn that I had leukemia.
Print Perspective Editor's Note: The errors led to considerable soul searching and, ultimately, a major change in institutional practices and culture. On December 3,year-old Boston Globe health reporter Betsy Lehman died of complications of an overdose of cyclophosphamide, a chemotherapeutic agent she received at the Dana-Farber Cancer Institute for treatment of breast cancer.
The media reported the event intensively, with 28 front-page headlines over the next 3 years. During those years, another patient, Maureen Bateman, also had a cyclophosphamide overdose and suffered serious heart damage.
The events devastated these patients' families, the clinicians who cared for them, and leaders of the organization. Both errors involved breakdowns in standard processes, and both raised issues of trainee supervision, nursing competence, and order execution.
The Massachusetts Department of Public Health; the Boards of Registration responsible for licensing physicians, nurses, and pharmacists; and the Joint Commission on Accreditation of Healthcare Organizations conducted investigations of the Dana-Farber, and the results were widely publicized.
The investigation identified numerous deficiencies, including protocol violations, ineffective drug error reporting, and oversight of quality assurance by hospital leaders. Inside the institute, the consequences of the incident reverberated broadly.
With high-profile resignations, reorganization of services, and regular media lashings, the mood was despondent. Then-president Christopher Walsh announced, "We are turning the place upside down.
The initial changes were sweeping: New rules were adopted mandating close supervision of physicians in fellowship training. Nurses were required to double-check high-dose chemotherapy orders and to complete specialized training in new treatment protocols.
Interdisciplinary clinical teams reviewed new protocols and reported adverse events and drug toxicities. A trustee-level quality committee was reorganized and strengthened. Discussions were begun regarding the transfer of inpatient beds to nearby Brigham and Women's Hospital.
Although these changes in training and organization were real and important, the ultimate changes wrought at Dana-Farber proved to be far more profound and sustained than one might have expected at the outset.
The transformation had less to do with the reorganization of clinical care than of the acceptance and integration of several key principles into the life and work of the organization. First, we learned that safety—if it was to be a core property of our system of care rather than an empty mantra—is the responsibility of clinical and administrative leaders and of our trustees.
Rather than creating a patient safety office, we gave senior clinical leaders responsibility for critical roles in patient safety. We decided that patient safety was and is the work of the organization, not an activity that could be compartmentalized.
In the same spirit, we decided that patient safety issues and problems would be reported directly up for board-level review, rather than to a staff-level subcommittee.
Second, we accepted the need for relentless vigilance for risk, error, and harm. We developed and refined error reporting through pharmacy interventions, incident reports, and patient safety rounds. We embedded in our practice a robust root cause analysis system to analyze critical incidents, report the results, and implement improvements.
We also created monthly management meetings in which members review events and analyses and take responsibility for implementing improvements. Third, we embraced the role of system design in the prevention of error and of information technology as a particularly powerful forcing function for delivering chemotherapy safely.Case Study Dana-Farber Cancer Institute The urban campus of Dana-Farber Cancer Institute in Boston is representative of many modern metropolitan healthcare institutions today, with a main campus in a busy city center that takes advantage of every available square inch.
Dana-Farber Cancer Institute case study solution, Dana-Farber Cancer Institute case study analysis, Subjects Covered Process analysis by Richard Bohmer, Ann Winslow Source: Harvard Business School 17 pages.
Case Study Dana-Farber Cancer Institute The urban campus of Dana-Farber Cancer Institute in Boston is representative of many modern metropolitan healthcare institutions today, with a main campus in a busy city center that takes advantage of every available square inch.
The Dana-Farber Cancer Institute Case Study 1. How did DFCI come about? The Dana-Faber, as it is commonly known, was originally established as the Children’s Cancer Research Foundation in by Dr.
Sidney Farber, then a pathologist at Boston’s Children’s Hospital. Access to case studies expires six months after purchase date. Publication Date: May 10, Despite revenues in excess of $93 million in , world-renowned Dana-Farber Cancer Institute.
Case Study: Adding Venetoclax to Azacitidine for Patients with AML. Advances in Hematologic Malignancies Issue 8, Spring We are actively accruing patients at Dana-Farber Cancer Institute for these three studies.
Figure (Konopleva M et al., Cancer Discovery, , ). Mechanism of action of venetoclax.