News Feature

Hospitals Prescribe IT for Medication Errors

By Susannah Patton

November 01, 2000 — CIO —

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Betsy Lehman was admitted to Boston’s prestigious Dana-Farber Cancer Institute on Nov. 14, 1994. Lehman, a respected health columnist for The Boston Globe, had volunteered for an experimental high-dose, four-day chemotherapy treatment for her recurrent breast cancer. She would then undergo a bone marrow transplant to restore immune and blood-forming cells. Instead, the 39-year-old mother of two received four times the prescribed dosage of the toxic anticancer medication. Although Lehman complained of weakness and nausea, hospital staff didn’t notice that a resident doctor had mistakenly prescribed the total four-day dosage to be given daily for each of the four days. Lehman died three weeks later, not of breast cancer but of heart failure caused by the massive medication overdose.

Six years and several lawsuits later, Lehman’s memory still haunts Dana-Farber. On a rainy August afternoon, doctors sit at computer terminals filling out drug and chemotherapy prescriptions with a customized system designed to prevent mistakes. If a doctor types in a 200-milligram prescription instead of the intended 20 milligrams, for example, the computer indicates the possibility of an error. Pharmacists check and double-check the orders against patients’ electronic records, and nurses check again, as patients sit quietly awaiting chemotherapy.

"Many organizations would have been in their bunkers," says James Conway, Dana-Farber’s COO. "We said, ’There’s been an unbelievable tragedy. Let’s make sure it doesn’t happen again.’ We still carry the burden of what happened here."

Dana-Farber is one of a handful of medical centers that has spent years developing an automated system to reduce medication errors. Health-care CIOs and doctors at treatment centers from LDS Hospital in Salt Lake City to Kaiser Permanente in Oakland, Calif., and the Veteran’s Administration Hospital in Topeka, Kan., argue that the increasing complexity of treatment and the sheer number of available medications make automation more of a necessity than ever.

The Quiet Killer

After the Washington, D.C.-based Institute of Medicine (IOM) of the National Academy of Sciences published a report in November 1999 highlighting the prevalence and consequences of medical errors, hospitals have been increasingly turning to IT for a safety check. As the national debate over this issue reaches a crescendo, many organizations are preparing to invest millions in computers, bar-coding scanners, robotic dispensers and other technologies designed to help health-care providers navigate the increasingly complex medical landscape.