Every day, the staff of the Dana-Farber Cancer Institute in Boston carries a collective burden over an unintentional chemotherapy overdose that led to the death of a breast-cancer patient in 1994.
But James Conway, Dana-Farber’s senior vice president and chief operating officer, said carrying that burden is not good enough.
The medical error that killed Betsy Lehman, a Boston Globe health reporter, ultimately became the impetus that has propelled Dana-Farber to its status as a national leader in the prevention of medical errors, reshaping an institution that was already among the most reputable cancer centers in the country.
Rhode Island's Market Has Changed. Developers, Builders, Investors and Sellers Must Change With It.
By Emilio DiSpirito IV License Partner | Engel & Völkers Oceanside Leader | The DiSpirito…
Learn More
“We’ve unleashed the power of that tragedy and used it as a lever to take the institution to an entirely different place,” Conway told an audience of about 150 nurses and other health-care workers during a forum on medical errors May 21 at Rhode Island College. The forum was sponsored by the United Nurses & Allied Professionals, which represents 4,000 registered nurses and other health-care professionals in Rhode Island.
Conway said regulations that require the reporting of medical errors only scratch the surface of the medical-errors issue. To get a sharper picture of what the real problems are, hospital administrators need to dig.
“And when you go looking for medical errors, you find them,” he said.
Every health-care worker has a story to tell – if not about a clinical mistake, then surely about a near-mistake – Conway said. Dana-Farber provides its staff members with a forum to discuss those incidents in detail, he said.
The center also has implemented a safer and simpler medication system and put the institute’s executive management and board of trustees at the leading edge of the drive to improve patient safety.
The forum at Rhode Island College also included a presentation by Dr. Joseph Amaral, president of Rhode Island Hospital – another well-respected health-care institution that has suffered from high-profile medical mistakes.
Earlier this year, the hospital disclosed that a surgeon cut into the wrong side of a patient’s head after a CT scan had been placed incorrectly on an X-ray viewing box. A year earlier, a surgeon removed the tonsils of the wrong patient, a girl who was supposed to have eye surgery.
Both Amaral and Conway talked about the importance of designing systems that make it harder for clinicians to make mistakes in the first place.
“It’s the job of the institution to put systems in place to protect (clinicians) from making errors,” Amaral said. “Errors more often than not occur when we deviate from standard operating procedures,” and Amaral said he thinks hospitals generally are lax in making sure standard operating procedures are rigidly folowed.
When mistakes do occur, Amaral said there needs to be a systemic analysis of the root cause, instead of focusing on the “longstanding, widespread tradition” in medicine to place blame when something goes wrong.
Indeed, Conway said a big part of bringing the issue of medical errors into the light of day – and hence effecting change – is to remove the element of complicity.
“We have to make sure nobody gets beat up over coming forward or being involved in an incident,” Conway said. “We have to ensure an interdisciplinary review.”
In a sense, both Dana-Farber and Rhode Island Hospital are fortunate in that each had a seminal event that prompted the institution to look at the medical-error issue anew. But, in the absence of a defining moment, Conway said the onus of improving patient safety falls to a health-care institution’s leaders.”We had exceptional physicians, nurses, and pharmacists at the time” of the lethal chemotherapy overdose, Conway said. “The problem was we didn’t have a conductor, a leadership team who conducted care. We let our organizational charts get in the way of interdisciplinary practice.”
Conway said that leadership has to include the board of trustees. Dana-Farber’s board gets frank, detailed updates on patient-safety and medical-errors issues at every board meeting, he said.
“We don’t show our board numbers, we tell them stories,” Conway said. “We want to show them the patient, tell them what happened.”
A final component of patient safety is so obvious that Conway said many health-care institutions overlook it: the role of the patient.
Conway has spoken with many patients or family members around the country who have been victims of medical mistakes. They invariably give him one dejected message: “I wanted to talk to someone, and all (the hospital) gave me was a lawyer.”
Instead of shunning patient input, Dana-Farber has embraced it, Conway said, bringing patients into the fold as it relates to the design, delivery, assessment and improvement of care.
Patients sit on the institute’s patient-education committee – a body that exists in almost every hospital, but rarely do they involve patient input, Conway said. Dana-Farber patients often accompany doctors on their rounds, talking to other patients about living with cancer. And they inform clinicians about what it’s like to suffer from the disease.
In recent years Dana-Farber has begun offering acupuncture, aromatherapy, therapeutic massages and information on herbal supplements – all the result of patient requests, Conway said.
“(Patients) are constantly telling us things we don’t know,” Conway said. “It helps us to improve our prioritization.”
