Chemotherapy

Chemotherapy – How Much Safer is it?

David Warsh, a “Globe” reporter, later wrote about the last day of Betsy’s life.²³ That day, Betsy felt as if something was wrong, very wrong. She phoned a friend and left a message. “I am feeling frightened, very upset. I don’t know what is wrong, but something’s wrong.” It was almost as if a sense of doom overwhelmed her. An hour later, Betsy was dead. What happened to Betsy?

She had received a four-fold overdose of a potent chemotherapy drug that had been intended to treat her cancer. Betsy received 26 grams of a cancer-fighting agent over four days. She was supposed to receive 6.5 grams. Betsy 39, died the day she was scheduled to go home to her husband and two children, 3 and 7 years old. Along with Betsy, although not well publicized, another women received an overdose of chemotherapy during the same period as Betsy. The woman had to be rushed to the intensive care unit for treatment of drug toxicity. She survived.

Betsy’s case received extensive national attention primarily because of her position with the Boston Globe. A later investigation revealed there was a series of latent conditions and system design flaws that allowed for such a large misinterpretation of the physician’s order. As a result of her death, there was public outcry and the Dana-Farber Institute made significant improvements to prevent this type of error from recurring. Still, nine years later, people are being harmed by medical errors related to chemotherapy and other toxic drugs.

In November 1997, in a New Jersey teaching hospital, a ten-month-old died after receiving 204 mg instead of 20.4 mg of Cisplantin, a potent chemotherapy medication.

In the summer of 2002, at a Maryland Hospital, a 2-year-old boy lost his hearing after receiving an overdose of a chemotherapy drug called, Carboplatin. A health official stated, “It's clear their systems broke down. They miscalculated the amount of the drug, gave the wrong dose three days in a row, and we have a bad outcome."

In December 2003, 2 year-old Brianna who suffered from cancer died at the John Hopkins Children’s Center of a potassium overdose. Brianna’s parents stated that their little Brianna died as a result of “ a cascade of failures”.

Since Betsy died, progress has moved slowly toward preventing overdoses of chemotherapy and other toxic medications. A study from the American Journal of Health-System Pharmacy (Phillips & Beam) on medication related deaths, studied between 1993 and 1998, found that chemotherapy errors were the second most common cause of death.

Obstacles to improvements in Safety

Why are the reductions in medical errors moving slowly? The obstacles to make swift changes are complex. Because health care leaders recognize the severity of the problem and often make small, incremental improvements in processes as errors occur. However, most of these changes do not address large-scale system redesigns to substantially minimize latent conditions.

With each significant error, a hospital team internally investigates the facts and immediate steps are taken to prevent recurrence. Yet, it is clear that larger system re-designs such as, integrated computer systems, automated checks of medication administration, fail proof medical equipment and safer environments to prevent human error must be implemented. On the other hand, these re-designs are expensive and take time to implement. Additionally, research on patient safety solutions is limited because many of the proposed safety solutions are new and not well tested in an actual patient environment.

Another reason for the slowness to change is because hospital tracking mechanisms for errors are convoluted and fragmented. The data collection, analysis and reporting of injuries are not standardized and the data are often buried in an information quagmire. Current internal data systems have limitations and are often considered subjective since they are not controlled to the extent of sound clinical research data.

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