Full text of DOI:10.1016/S0899-5885(02)00017-5

Crit Care Nurs Clin N Am 14 (2002) 359–367
Multidisciplinary approaches to reducing error and risk
in a patient care setting
a,
a,b
*
Maureen Connor, RN, MPH, CIC , Patricia Reid Ponte, RN, DNSc ,
James Conway, MBAa
aDana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, USA
bDepartment of Nursing, Brigham and Women’s Hospital, Boston, MA 02115, USA
When Dana-Farber Cancer Institute (DFCI) of
Boston became the setting of a highly publicized
drug overdose incident in 1995, nurses, administra-
tors, physicians, clinical and other staff, patients and
family members, and trustees were all affected by the
event on some level. ‘‘How could this have hap-
pened?’’ 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.
another resulted in permanent heart damage. The
patient who died was a 39-year-old mother of two
with advanced breast cancer who was receiving
experimental treatment preceding a bone marrow
transplant. Both patients were given an overdose of
chemotherapy. The error resulted from written mis-
communication about total versus daily dose. Pro-
cesses in place were not designed to catch the error.
The patient died suddenly the day before discharge,
but it was not until 2 months later that a data manager
identified an error as the cause of death. In the
months and years since, there have been intense
media scrutiny (the patient who died was a newspaper
columnist); a temporary conditional accreditation by
Joint Commission on Accreditation of Healthcare Or-
ganizations (JCAHO), suspension of several members
of the staff; reprimands of involved staff by the state
nursing, pharmacy and medical state boards; and con-
tinuing litigation [1].
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 bene-
ficial for others refining patient and staff safety and
service programs.
Investigations into the event found that commu-
nications between various health professionals
around clinical care were discipline specific rather
that interdisciplinary [1]. The tragic event, however,
has resulted in a rebirth of systems and process
improvements at DFCI and an institutional commit-
ment to quality and safety.
Background
Two tragic medication errors occurred at DFCI in
November 1995; one resulted in a patient’s death, and
Patient safety premises
At least 44,000 people, and perhaps as many as
98,000, die in hospitals each year as a result of
medical errors that could have been prevented. More
than a million people in the United States suffer from
* Corresponding author.
E-mail address: maureen_connor@dfci.harvard.edu
(M. Connor).
0899-5885/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S0899-5885(02)00017-5

360
M. Connor et al. / Crit Care Nurs Clin N Am 14 (2002) 359–367
preventable medical injuries. Preventable medical
errors have been estimated to result in total costs
(including the expense of additional care necessitated
by the errors, lost income and household productivity,
and disability) of between $17 billion and $29 billion
per year in hospitals nationwide [2]. As those
involved with DFCI discovered, medical errors and
concerns about medical errors can lead to a loss of
trust by patients, staff, and other supporters and can
reduce staff morale and sense of purpose.
excelled at their work but who needed a stronger
conductor—not a person so much as systems that
made working together the basis of everyday practice
[6]. Senior clinical team leadership and multidiscipli-
nary committees began to collaborate more fully
around patient care with shared responsibility and
integrated improvement, including medication safety.
One example of multidisciplinary teamwork at
DFCI is the Medication Event Subcommittee, a
subcommittee of the Pharmacy and Therapeutics
Committee. This group convenes monthly and
reviews all reported medication events that occurred
during the previous month. The team is comprised of
leaders and staff from nursing, pharmacy, medicine,
and risk management representatives and expands as
necessary. For example, it is not unusual to have staff
from Information Services. All events are outlined on
a grid and are severity rated. Each medication event is
reviewed in detail, with a focus on contributing
factors, systems issues, and trends occurring over
time. In essence, a ‘‘mini’’ root cause analysis is
performed on every event. The data are reviewed in a
blind fashion so that no practitioner’s name is
assigned to any of the events.
DFCI staff rebuilt its patient safety culture based
on some basic assumptions about medical errors.
First, it is well recognized within the health care
community that the vast majority of medical errors
are caused by systems problems rather than poor
performance on the part of individuals [2]. A major
cause of these systems problems can be attributed to
the complexity of the health care environment today.
The challenge posed to nurses and other practitioners
by the shear amount of information available and the
rate at which this information changes is daunting.
This need for information and other human factors,
such as competing demands for time and working
when fatigued, are indicative of why systems need to
be created to help support staff in their work of
safeguarding patients. Systems need to be designed
that make it harder for people to do something wrong
and easier for them to do it right [2] because, as
health care safety expert Donald Berwick, MD,
reminds us, ‘‘Every system is perfectly designed to
achieve exactly the results it gets’’ [3].
The true success of bringing this team together is
evident in the number of systems improvements that
have been made. As an example, the team was able to
enhance patient safety around opiate administration
when a problem was identified through adverse drug
reaction reporting and incident reports. The Medica-
tion Event Subcommittee identified a number of
interventions that included major revisions to the
guidelines for opiate administration, establishment
of standard concentrations for opiates and a rate of
administration chart, and the implementation of pain
and symptom management nurses rounding daily.
The Pain and Symptom Management Team also
developed an evidence-based educational program
for nurses and pharmacists to attain and maintain
competency in the principles of pain management. In
reviewing the interventions made, they would not
have been nearly as effective or comprehensive
without the input from all of the disciplines involved.
Another approach to working in teams where a
nursing presence is critical is in multidisciplinary
patient safety rounds. A pilot project was recently
completed in the ambulatory clinics. The pilot con-
sisted of a team comprised of a nurse manager, a staff
nurse, a pharmacist, and a risk manager periodically
rounding in various clinics and asking staff if any-
thing interfered with their providing safe patient care.
This process fostered an open, supportive environ-
ment in which to share concerns and resulted in an
extraordinary amount of information. Initial concerns
Multidisciplinary approaches
Patient safety cannot be accomplished without
interdisciplinary practice approaches. Safety depends
upon implementation of a unified interdisciplinary
system of physicians, nurses, and all other health care
personnel that addresses the realities of practice and
patient care. Patient safety gains are unlikely to be
achieved at a satisfactory pace in the absence of
revolutionary changes [4]. At DFCI, staff knew that
business as usual must change—patient safety could
not wait for the usual pace of change in the health
care system.
Cooperation among clinicians is a priority. Clini-
cians and institutions should actively collaborate and
communicate to ensure an appropriate exchange of
information and coordination of care [5]. At DFCI,
staff identified the improvement of interdisciplinary
practice as critical to implementing change.
One administrator described the clinical staff of
DFCI as a group of hard-working virtuosos who

M. Connor et al. / Crit Care Nurs Clin N Am 14 (2002) 359–367
about the nurse manager’s involvement impeding Nonpunitive environment
361
staff’s ability to openly discuss errors proved un-
founded. This pilot was so successful that it has
become a permanent program.
Fundamental to creating an atmosphere that
focuses on developing safer systems is the promotion
of a nonpunitive environment in reporting errors.
This represents a basic shift away from the culture
of blame. The role of leadership from all disciplines is
essential in promoting a nonpunitive environment.
Leaders must make this cultural shift an organiza-
tional priority and lead by example. When errors are
discovered at DFCI, staff are encouraged to report
them without the fear of reprisal. Staff are also
encouraged to report ‘‘near misses’’ or ‘‘close calls,’’
those errors that are corrected before reaching a
patient. Some of the most significant changes in
practice result from reviewing these near-miss events
that might otherwise go unnoticed until a serious
error results in patient harm. In the subsequent review
of these close calls and errors, staff focus on uncov-
ering contributing factors to the event and identifying
necessary systems improvements. Thus, staff are not
only an integral part of this review process; they are
also encouraged to be part of the solution.
Executive leadership
Safety should be an explicit organizational goal
that is demonstrated by strong leadership on the part
of clinicians, executives, and governing bodies [2].
Leadership is essential. In its absence, efforts will be
fragmentary, uncoordinated, and have only minor ef-
fects [7].
Leadership is needed to redefine accountability.
Some have been concerned that not punishing people
for making errors relieves them of responsibility. The
converse is true. In a safety-oriented organization,
every employee feels and accepts responsibility to
identify unsafe conditions, report them, and work
toward their elimination [7].
After the overdose incident, the Dana-Farber
Board of Trustees was devastated. Many trustees
were sophisticated business people who knew that
safety and customer service were paramount in busi-
ness yet were surprised to think of these issues in the
context of health care. Before the overdose, like many
boards, the expertise of Dana-Farber Board members
was underutilized.
Focusing on systems issues as the source of
medical error does not eliminate the need for holding
individuals accountable. Rather, it helps organizations
to focus on those few circumstances in which indi-
vidual culpability exists. Fig. 1 illustrates a decision
tree that provides a useful framework to distinguish
between systems issues and individual accountability.
Board members and executives must be seen as
committed to a culture of patient safety, aware of the
practice issues in their organizations, and actively
involved when issues of safety are discussed [8]. At
DFCI, executive leadership now personally leads and
is accountable for an ongoing safety program. They
set the tone by creating a series of recommendations,
including the creation of a committee that meets five
times a year specifically to review safety initiatives
and make recommendations. Drawing on this experi-
ence, the DFCI chief operations officer authored
Strategies for Leadership for the American Hospital
Association, a self-assessment tool for all executives
within health care organizations. The tool gives
individuals and groups of leaders a range of choices
to consider, periodically revisit, and use to trigger
actions within organizations. Among the almost 40
elements of the tool is a section that urges leadership
to ‘‘set the expectation for timely and interdisciplin-
ary error and near-miss investigations with an
emphasis on: patient/family impacted by the error;
the broader institutional implications of learning from
the error; and the support of staff at the sharp end
(closest to care)’’ [9]. This has been accomplished in
large part through the root cause analysis process
detailed later in this article.
Designing processes
Chemotherapy order entry
Given the basic premise that human beings have
limitations and are prone to error and that many of our
existing systems fail to prevent these errors, the
preventive measures required become more obvious.
For example, the medication administration process is
a complex system with multiple handoffs among sev-
eral different disciplines. The number of actual steps
in the process from ordering medications through
administration may range from 20 to 40 or more, de-
pending on each institution’s process. This illustrates
the need for systems to be hard wired to prevent
errors. A good example of hard wiring the medication
administration system is through forcing functions,
such as adding high dose warnings to computerized
chemotherapy order entry systems. This process elim-
inates the need for total reliance on the practitioner’s
memory when ordering medications.
Like many institutions that have traced the root
cause of medical errors, DFCI discovered early on that
behind human error is often an array of system errors.

362
M. Connor et al. / Crit Care Nurs Clin N Am 14 (2002) 359–367
Fig. 1. Decision tree for determining the culpability of unsafe acts. (From Reason J. Managing the risks of organizational
accidents. Hampshire, England: Ashgate; 1999. p. 209; with permission.)
One of the first corrective actions following the tragic
overdose was to put in place a computerized system
for chemotherapy and other drug orders. This sys-
tem takes pieces of the medication administration
system out of human hands and gives it to a computer
with built-in safeguards. A comprehensive system of
double- and triple checks is part of the process [1].
Central to many information technology applica-
tions is the automation of patient-specific clinical
information, essential to managing chronic illnesses
(eg, cancer) that require frequent monitoring and
ongoing patient support [5]. Slips of paper, handwrit-
ten scribbles. and lined paper that can easily hide a
decimal point are eliminated from the process.
Instead, physicians use an electronic form for typing
the patient’s name, weight, and height (critical to the
dosage) and for indicating the intended drug, dose,
and number of days it is to be administered. The com-
puter compares these data with a pre-programmed set
of drug-specific guidelines with established high-dose
limits and routes of administration. These guidelines
were developed based on scientific literature and
drawing on expertise in the field. The primary focus
is on the ‘‘five rights’’: Give the right dose to the right
patient in the right route and dose at the right time.
If a physician makes a mistake—for example, typing
250 milligrams instead of 25 milligrams—the com-
puter signals a possible error. Over-rides are possible
only by designated attending physicians and are
double- and triple-checked by pharmacists and nurs-
ing before taking off the order and dispensing [1].
The computerized systems cost $1.7 million and
involve integrating a pharmacy checking system and
an order entry system [1]. This system has been
upgraded recently. Continuous template revisions,
improved capabilities, and general enhancements
are necessary. For instance, adding forced hydration
order sets for patients receiving chemotherapy, which
requires hydration before administration, was one
recent enhancement.
Other computerized efforts that have contributed
to the culture of patient safety are providing clinician
access to online clinical trial protocols, a clinical
pharmacist program, and electronic medical records.
Root cause analysis
Another process implemented at DFCI is the root
cause analysis (RCA). Immediately upon learning of a
critical event, a RCA team is convened to review all of
the details (Table 1). The team is comprised of senior
clinical and administrative staff from nursing, phar-
macy, medicine, risk management, and other areas as

M. Connor et al. / Crit Care Nurs Clin N Am 14 (2002) 359–367
363
appropriate. Most importantly, the staff members who
were involved are at the table. Throughout the pro-
cess, senior leaders are visible. This forum provides an
opportunity for staff members to share their story.
Because the underlying cause of most critical events is
often multifactorial with more than one discipline
involved, it is particularly beneficial to have all of
the staff closest to the event or at the ‘‘sharp end’’ of
the error sharing their stories together. When these
stories are conveyed in this type of forum, a level of
learning takes place that is powerful and enduring.
The RCA process asks why—and why again. For
example, if poor communication is identified as a
contributing factor, human factor issues are assessed.
Was the nurse or pharmacist distracted because the
work area was overcrowded, or were there too many
competing demands because of inadequate staffing?
The contributing causes are then identified, and an
action plan is developed.
senior clinical or administrative leader should also be
present for the most complex cases. The clinician
serving as the spokesperson should be prepared for
the presentation of facts and anticipated questions.
It is important for organizations to plan for ques-
tions regarding compensation by patients and families
for damages as a result of the medical error. Each
medical error differs in complexity and losses or
damages to patients; therefore, risk managers, medical
ethicists, and hospital lawyers need to be involved in
the review of the most complex errors. An important
principle that should serve as an underpinning of the
entire process is that the error occurred, the patient and
family have a right to be angry or upset, and that the
organization must respond in a meaningful way. Dur-
ing the meeting, an apology should be made and an
assurance given that a full analysis of the events
leading to the error will take place. It is critical to plan
follow-up meetings with the patient and family. It will
more often than not be necessary to address questions
and concerns as additional information becomes avail-
able and as patients and family members have an
opportunity to comprehend the full nature of the event.
The clinicians involved in the error will also require
follow-up. Feelings of guilt, blame, lack of confidence,
and despair often follow for a clinician involved in a
medical error despite the understanding that poor
systems may have played a role. Clinicians should
have an opportunity to debrief after the event and have
support provided on an ongoing basis.
Patient and family disclosure
Disclosing medical errors to patients and families
is one of the primary actions required by clinicians
and health care administrators after the discovery of
an error. Promotion of a culture that supports a non-
punitive approach to medical error reporting provides
the necessary foundation to support staff in openly
discussing adverse outcomes. A nonpunitive report-
ing culture supports accountability at the individual
and system levels.
Assuming that a culture of nonpunitive reporting
exists, clinicians and other staff will be guided by
disclosure policies in the event of a medical error.
Disclosing these events is a demanding, stressful
process that must be guided and supported in a
sensitive and assertive manner by clinical and admin-
istrative leaders. Several steps must be taken. First, the
primary physician and nurse involved in the care of
the patient should be contacted immediately after the
discovery of an error. Second, the error should be
reviewed carefully in a multidisciplinary conference
by phone or in person to assure that what is believed to
have occurred actually did. Errors should be disclosed
to patients and family members as soon as is rea-
sonably possible, typically within 24 hours after the
error occurred or is discovered. Third, a formal root
cause analysis must be conducted in a forum invol-
ving all possible links to the cause of the error.
The meeting with the patient and family is often a
very difficult and stressful event and, depending on
the situation, may occur before all of the contributing
factors are known. It is very important that the
attending physician and primary nurse be present at
the family meeting, if at all possible. In addition, a
Patient and family involvement
Perhaps one of the most dramatic efforts at DFCI
has been the introduction of formal participation by
patients and families in patient care [10]. An Adult
Patient and Family Advisory Council was begun in
1997, and a Pediatric Council was started in 1999. The
adult council consists of 15 patients and family
members and nursing and physician staff members.
The council has participated in a wide range of
projects, including parking fees, billing systems,
emergency procedures, waiting times, and a news-
letter. The council has it own office, and members
conduct patient care rounds, asking patients and
family members about their experiences at DFCI and
Brigham and Women’s Hospital where inpatient care
takes place. Council members meet regularly with
first-year oncology fellows to share their experiences
and participate in other forums as requested by staff.
The council’s involvement and, consequently, the
patient’s point of view are hard-wired into the DFCI
system through council members’ involvement on
three standing committees: the Adult Oncology Clini-

364
M. Connor et al. / Crit Care Nurs Clin N Am 14 (2002) 359–367
Table 1
A framework for a root cause analysis and action plan in response to a sentinel event
Root
Take
Level of Analysis
What happened?
Questions
Findings Cause? Action?
Sentinel event
What are the details of the
event? (Brief description)
When did the event occur?
(Date, day of week, time)
What area/service was impacted?
What areas/services/departments
are participating in the root
cause analysis?
j
j
j
!
Why did it happen?
The process or
What are the steps in the process,
as designed? (A flow diagram
may be helpful here)
activity in which
the event occurred
What were the most
proximate factors?
(typically ‘‘special
cause’’ variations)
What steps were involved in
(contributed to) the event?
What human factors were
relevent to the outcome?
Who is involved? (Elements
that may have contributed to
decision, beginning to end
statement of each persons role)
What organizational factors are
relevant to the outcome?
What policies or procedures
affected the outcome?
j
j
j
j
j
j
j
j
j
j
Human factors
Organizational
factors
P&P factors
Equipment factors
How did the equipment
performance affect the outcome?
What factors directly affected
the outcome?
Controllable
environmental
factors
Uncontrollable
external factors
Other
Are they truly beyond the
organization’s control?
j
Are there any other factors that
have directly influenced this outcome?
What other areas or services
are impacted?
!
Why did that happen?
What systems and
processes underline
those proximate
Human
To what degree are staff properly
qualified and currently competent for
their responsibilities?
resource issues
How did actual staffing compare
with ideal levels?
factors? (Common
cause variation here
may lead to special
cause variation in
dependent processes.)
What are the plans for dealing with
contingencies that would tend to
reduce effective staffing levels?
To what degree is staff performance
in the operant process(es) addressed?
How can orientation & in-service
training be improved?
j
j
j
Information
To what degree is all necessary
management issues information available when needed?
accurate? complete? unambiguous?
!
(continued on next page)

M. Connor et al. / Crit Care Nurs Clin N Am 14 (2002) 359–367
365
Table 1 (continued)
To what degree is communication
among participants adequate?
j
j
j
j
j
j
j
j
j
Environmental
To what degree was the physical
environment appropriate
management issues
for the processes being carried out?
What systems are in place to identify
environmental risks?
What emergency and failure-mode
responses have been planned and tested?
To what degree is the culture conducive
to risk identification and reduction?
What are the barriers to communication
of potential risk factors?
Leadership issues:
Corporate culture
Encouragement
of communication
Clear
To what degree is the prevention of
adverse outcomes
communication
of priorities
communicated as a high priority? How?
What can be done to protect against the
effects of these uncontrollable factors?
j
j
Uncontrollable
factors
!
Framework for an action plan in response to a sentinel event
Measures of
effectiveness
Risk reduction strategies
Responsibility
Date
For each of the findings identified in
the analysis as needing an action,
indicate the planned action, expected
implementation date, and associated
measures of effectiveness, OR. . .
If, after consideration of such a
finding, a decision is made not to
implement an associated risk
Action item #1:
Action item #2:
reduction strategy, indicate the
rationale for not taking action at
this time.
Check to be sure that the selected
measure will provide data that will
permit assessment of the effectiveness
of the action.
Action item #3:
Consider whether pilot testing of a planned
improvement should be conducted.
Improvements to reduce risk should
ultimately be implemented in all areas
where applicable, not just where the
event occurred. Identify where the
improvements will be implemented.
Action item #4:
Action item #5:
Cite any books or journals articles that were considered in developing this analysis and action plan:
Final summation of case: Lessons learned, Improvement opportunities, Problems encountered
RCA completed by:
name/title
date
Adapted from Joint Commission on Accreditation of Healthcare Organizations, Joint Commission resources. Root cause analysis
in health care: tools and techniques. Joint Commission on Accreditation of Healthcare Organizations: Oakbrook Terrace, IL;
2000; with permission.)

366
M. Connor et al. / Crit Care Nurs Clin N Am 14 (2002) 359–367
cal Services Quality Improvement Committee, where
council members review information on all types of
patient issues, including falls and errors; the Care
Improvement Committee; and the Patient/Family
Education Committee (see Box 1).
ronment that is much more supportive of safety and
privacy for patients, family members, and staff.
Next Steps
Health care organizations, professional organiza-
tions, managed care and insurance industries, and the
clinicians and administrative staff who provide care
must partner with citizen groups and patients and
families to create policies that address patient safety.
Key to this work is a commitment to the valid tenets
of a high quality continuous learning and a system-
improvement oriented culture. The most recent Insti-
tute of Medicine report, ‘‘Crossing the Quality
Chasm’’ (2001), highlights the importance of this in
two principles: (1) Safety—Create cultures of nonpu-
nitive reporting, strong interdisciplinary collaborative
practice and systems improvements; and (2) Patient
centeredness—partner with patients and families not
only to improve each individual’s experience in treat-
ment but also to use the collective voice of these
uniquely informed participants to make health care
systems truly responsive to those receiving care [2].
Creating an environment within the health care
system to assure the safest, collaborative care model
is the responsibility of every nurse, physician, phar-
macist, and health administrator. Starting in a small
ways, such as the initiation of ‘‘safety rounds’’ or not
reacting with blame, are steps that can be taken now.
In addition to the shift to a nonpunitive culture
within our organizations, the challenge confronting
health care professionals is how to initiate this change
externally as well. This needs to occur within schools
of nursing, medicine, and allied health where our
providers learn about the notions of perfection and
blame. This cultural shift needs to be embraced by
professional societies and organizations that establish
standards of practice and needs to be embodied in
regulatory agencies and licensing boards whose mis-
sion is to safeguard the public.
Box 1. A week at DFCI: Activities
involving patients and family members
ꢀ
Adult Oncology Clinical Services
Committee
ꢀ
Facility Planning
The Patient Education Committee
Patient Care Rounds
Patient Educator Program
Joint Quality Improvement and Risk
Management Committee
ꢀ
ꢀ
ꢀ
ꢀ
ꢀ
Complementary Therapy Task Force
Working on the wait
Emergency admits
Policy review
A Friday meeting with the
administrator
ꢀ
ꢀ
ꢀ
ꢀ
Through these formal channels, DFCI staff have
learned that patients and family members provide
information that simply would not occur to staff,
make significant contributions to improving prioriti-
zation and work processes, and are critical in answer-
ing the question: Is this change an improvement?
These formal provisions have led to opportunities
to informal, yet critical, channels of communication.
In one example, while at DFCI for treatment one
morning, a patient who was also a council member
used a phone in the infusion area to call the Chief
Operations Officer. The patient asked the executive to
come to the infusion area because he and other
patients did not feel completely safe. Based on pre-
vious experiences, this patient felt confident that if he
called on the executive leadership in the spirit of true
concern, he would get a response.
Working in collaboration with external agencies, a
common framework for analysis of medical harm/
errors needs to be identified that could exist among
boards, agencies, and health care institutions. This
collaborative relationship should seek to answer
whether systems thinking—individual and shared
accountability and responsibility—provide a frame-
work for health care. The key question is how can we
advance practice together. This is the major challenge
for healthcare leadership today.
The executive met immediately with patients and
family members and heard their concerns about
crowded conditions, the lack of privacy, and nurses
working in cramped and busy conditions. It was
uncomfortable for staff and patients, the group said,
and potentially dangerous. A renovation plan was
already in progress for the infusion area that would
have added seven beds. The executive stopped the
process and got patients involved in the redesign, and
the plans changed. Today, DFCI has an infusion envi-
The evolution of the DFCI has been one of learn-
ing and growth in this area. It takes time, commitment
by the senior leadership, and a strong patient-centered

M. Connor et al. / Crit Care Nurs Clin N Am 14 (2002) 359–367
367
[4] Executive summary of joint meetings of the Council on
Graduate Medical Education and the National Advi-
sory Council on Nurse Education and Practice. Collab-
orative education models to ensure patient safety.
Washington, D.C., September 13–14, 2000.
and multidisciplinary collaboration philosophy. This
is possible in all institutions that deliver care.
Acknowledgment
[5] Institute of Medicine, Committee on Quality Health
Care in America. Crossing the quality chasm. Wash-
ington, D.C.: National Academy Press; 2001.
[6] Mack DM, et al. Reducing medical errors, improving
patient safety: Taking the next step. HealthLeaders;
June 2001.
We gratefully acknowledge Cindy Whitcome’s edi-
torial assistance in the preparation of this manuscript.
References
[7] Leape L. Can we make health care safe? Accelerating
change today. Findlay S. (editor). A.C.T. for Ameri-
ca’s Health. Washington, DC: The National Coalition
on Healthcare; 2000. p. 2–3.
[1] Paul C. Back from the brink: making chemotherapy
safer. Findlay S. (editor). Accelerating change today.
A.C.T. for America’s Health. Washington, DC: The
National Coalition on Healthcare; 2000. p. 4–8.
[2] Institute of Medicine, Committee on Quality Health
Care in America. To err is human: building a safer
health system. Washington, D.C.: National Academy
Press; 1999.
[8] Conway J. Patient safety: it starts at the top. Chicago:
American Hospital Association; 2000.
[9] Conway J. Strategies for leadership: hospital execu-
tives and their role in patient safety. Chicago: Ameri-
can Hospital Association; 2001.
[10] Webster PD, Johnson B. Developing and sustaining a
patient and family advisory council. Bethesda: Institute
for Family Centered Care; 2000. p. 73–7.
[3] Berwick D. What does it mean to pursue perfection in
health care? Presented at the Pursuing Perfection
Launch Meeting, Institute of Health Improvement.
Boston, September 4, 2001.