Dana-Farber examines medication errors
Dana-Farber examines medication errors
CEO discusses changes since fatal error
It was, to use the hackneyed phrase, the mother of all medication errors: a fatal overdose of a chemotherapeutic given, with elegant irony, to a health reporter for The Boston Globe.
But Betsy Lehman’s death two years ago from an overdose of cyclophosphamide was apparently not in vain. Suddenly, it seems everyone is talking about medication errors few more fervently than officials at the institution in which she spent her last days the Dana-Farber Cancer Institute in Boston. (See Drug Utilization Review, January 1997, p. 1.)
James Conway, the hospital’s CEO, was recruited into his post shortly after the Lehman incident became public. His experience has taught him one thing about catastrophic medication errors: The trauma from such an incident can linger for a long time. "The error occurred almost two years ago and there is still not a day that goes by that it doesn’t come up," Conway says. "It continues to be part of the institution, it continues to be talked about."
Error reduction as part of QI plan
But Conway views that as a plus. "At Dana-Farber, one of our goals is continued improvement in the area of error reduction. We put the language of error reduction in the quality improvement plan," he says. "By making it visible, we have made it something we’re accountable for. We have to openly talk about the fact that errors happen every day."
Of course, simply talking about errors isn’t enough, Conway says. Executive leadership and adequate funding are also necessary for a strong error reduction program. "Error reduction strategies won’t be a success unless the leadership is aware of and endorses them. I think it’s the most critical message," he adds. "Executive leadership has to be engaged."
In other words, groups convened to review medication errors have to know the institution will stand behind their recommendations and provide money, if necessary, to see that quality improvements are carried out. "Groups get frustrated. They’re well-intentioned, but when they move forward to implementation, [they hear things like] there’s no money. He adds, "Senior leadership has to confirm support for the team and a commitment to success."
At Dana-Farber, a number of talking groups convened after the error both formal and informal. A medication-use team was put in place to review all hospital systems that had anything to do with drugs. Conway says the interdisciplinary team made up of pharmacists, nurses and physicians came up with a number of recommendations for improvements, including comprehensive monitoring of drug dosages and protocols. He says it was important for the pharmacy department to realize it didn’t have to go it alone in preventing medication errors.
"All of the literature suggests that errors occur 20% of the time because of individual mistakes and 80% of the time due to systems problems it could be in the pharmacy or in the hand-off to other professionals," Conway says. "Any pharmacy department that thinks errors are all their fault is destined to failure. A long-term reduction in errors should be interdisciplinary."
Conway recommends other hospitals considering a formal error reduction policy take a systems approach. In other words, avoid blaming the individual, and look for places along the way where the system has failed. He also says it’s important that those who review medication error data be directly involved in the drug distribution process. It’s fine to include quality control personnel, but more important, he says, that doctors, nurses and pharmacists be involved.
Errors occur every day, everywhere
Above all else, Conway says, hospital personnel need to be realistic about errors. "If there’s an error and there will be an error every day and people go for the jugular and say it will never happen again, then people will retrench. They won’t communicate and you don’t learn from the mistake."
Conway says pharmacy managers play a critical role in error reduction strategies because many mistakes involve drugs. "There are endless errors that occur in every big and little hospital that revolve around drugs. Nobody wants to publicly acknowledge errors occur in health care. But if we talk to patients they can go on ad nauseam about errors." In fact, Conway admits, errors might be occurring every day at Dana-Farber. "The good news is that with the new systems [in place] we’re able to prevent the vast, vast majority of errors from getting to the patient."
Conway says he’s sometimes asked a tough question by pharmacists: "Does it take a sentinel event to engage their organization’s leadership? Does something terrible have to happen before [hospital management] pays attention to [medication error] data?" Unfortunately, the answer is often yes. "But I would encourage pharmacy leaders not to give up," Conway says. "Continue to do what’s right for the patient."
As part of that strategy, Conway says Dana-Farber will launch a research program this year to study medication errors, perhaps proving Betsy Lehman’s death was surely not in vain.
The pharmacy’s perspective
Like Conway, Sylvia Bartell, BS, MS, assumed the directorship of Dana-Farber’s pharmacy shortly after the Lehman error. She says the error brought the staff closer together. "We’re here not to make mistakes, and when this happens people say It could’ve happened to me.’ " In fact, empathy for the pharmacists involved in the error cut across hospital lines. Bartell says pharmacists working in other hospitals in the Longwood Medical Area called to express support for their colleagues.
It was difficult for the staff to deal in silence with the local media, Bartell says, because there was a general feeling the whole story was not getting out. But following hospital policy, media calls were referred to public affairs. "It was frustrating to the staff. [The feeling was] If we could just tell them our story,’" Bartell says. "You know medication errors is something you want to hide but you need to tell the story and improve the situation."
Bartell says the interdisciplinary team charged with examining the medication error did three things. First, they looked at computer software what Dana-Farber had in place (a home-grown system) compared to what was available externally. Second, the hospital looked at nine other cancer centers to compare pharmacy operations. And finally, the team developed a flow chart to see how medications got to patients. "It was the first time we dissected all the steps," Bartell says, "and it gave us a better understanding of how each professional worked."
Based on these data, the hospital elected to upgrade its computer system in a number of ways, including the addition of dose ceiling information for chemotherapeutics. "We did not have this in the computer previously," Bartell says. "It sounds easy but dose ceilings can vary with radiation, for example. So many factors come into play." The ceilings, set by weight and body surface area, are set by both daily dose and dose cycle order, given physicians and pharmacists use different terms for chemotherapeutic doses.
Physicians wishing to override dose ceilings must provide documentation to the pharmacy, such as journal article. If no documentation is provided and the physician still insists on using an override dose, the pharmacist can take the matter to the chief of staff, if necessary.
Protocol standardization
With up to 200 protocols going at once in the hospital it was important to standardize ordering of drugs. Thus, the ordering template was born, with dosing information programmed in. Before passing to the template stage, protocols pass through a complicated sign-off process involving two pharmacists, a research nurse, and the physician running the protocol.
A drug-drug interaction system was also purchased. Bartell says they were looking for a system that highlighted significant drug interactions as opposed to one in which pharmacists would breeze through interaction warnings, knowing most of these were insignificant. The hospital wound up buying standard drug-drug interaction software and the pharmacy and therapeutics committee cleaned the package up to suit the institution’s needs.
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