The IOM report, "To Err Is Human," put forth some disturbing figures. Avoidable medical mistakes kill anywhere from 44,000 to 98,000 people a year-more than breast cancer, highway accidents or AIDS. The report also states that more than 7,000 deaths are caused by medication errors. Just as Lehman’s death shook Dana-Farber and other cancer centers, the IOM report has caused widespread soul-searching throughout the medical world.

That report has also pushed the issue to the forefront of national debate. Congress is holding hearings on patient safety, and a group of large employers, including General Electric and General Motors, is using its clout to call for specific changes like computerized drug orders to improve safety. The report offers a wide range of reforms and, most notably, recommends using computerized order entry, pharmaceutical software and other technologies to prevent mistakes. This national attention on increased safety and automation is giving health-care CIOs a broader forum as top administrators increasingly look to new technologies to improve care.

"Those at the leadership level have come to believe that IT is important to them," says John Glaser, vice president and CIO at Partners HealthCare System in Boston, comprising Brigham and Women’s Hospital and Massachusetts General Hospital. "I hope that technology will stay on their radar screen forever."

Although some have challenged the numbers in the IOM report and questioned its meth-odology, few contest the basic premise that medical errors-and medication errors in particular-can and should be reduced. "In any case, the death toll is higher than it should be," says Dr. David Bates, chief of general medicine at Boston’s Brigham and Women’s Hospital, which is often cited as a pioneer in the development of a computerized physician order-entry system for prescriptions. "The IOM report has clearly galvanized the industry."

Paperless Prescriptions

When a doctor wrote the prescription that ultimately led to Lehman’s death, computerized order-entry systems weren’t available at Dana-Farber. In the aftermath of this and another mistake that left breast cancer patient Maureen Bateman with a damaged heart, Dana-Farber staff members huddled to design a pharmaceutical management system specifically for oncology treatment. With nothing on the market, a team of four programmers developed software that helps doctors and pharmacists check a patient’s medication protocol and verify dosage amounts.

"It was a difficult time for everyone, including people in IS," says Dana-Farber’s CIO Ben Bembenek. "We felt that we should have been able to prevent this type of error. But at that point, no pharmacy system had dose level limits."