ABLEnews Extra

                    "Mistakes Will Be Made"

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A DEATH AT A BOSTON HOSPITAL RAISES THE QUESTION, 
ARE FRAZZLED DOCTORS MAKING TOO MANY FATAL MISTAKES?
   
If anyone knew how to get the best medical treatment, it was Betsy
Lehman. A health columnist who had worked at the Boston Globe since
1982, she had covered everything from leading-edge research to the
finer points of a physician's bedside manner. When she learned she had
an advanced case of breast cancer, she carefully studied her options
and chose to undergo an experimental treatment offered at the
Dana-Farber Cancer Institute, a prestigious hospital affiliated with
Harvard Medical School. Tragically, the 39-year-old mother of two died
in December. But as a front-page story in the Globe disclosed last
week, her death was not the result of her disease. The cause was a
huge overdose of a powerful anticancer drug accidentally administered
by the hospital's staff.
   
Lehman's case is just one of a spate of medical foul-ups that have
made headlines in recent weeks. In two Florida incidents, a doctor
amputated the wrong foot of a diabetic man, and a hospital worker
mistakenly turned off a stroke victim's breathing machine. In Michigan
a surgeon doing a mastectomy removed a woman's healthy breast instead
of the diseased one. Are these isolated, if horrifying, events? Or
could they be harbingers of a deadly trend? Though no statistical
evidence shows that malpractice is on the rise, state licensing boards
have stepped up their investigations of doctors. According to Public
Citizen's Health Research Group, the number of physicians who have had
their licenses revoked, suspended or restricted rose from 1,974 in
1992 to 2,190 in 1993, an 11% increase.
   
Still under intense investigation, Lehman's death appears to have
resulted from a mathematical error that wasn't discovered until
February, when two clerks undertook a routine review of her case. As
thousands of cancer patients know well, standard chemotherapy involves
figuring out a treatment that is aggressive enough to destroy a tumor
without also killing the patient. For each person, doctors must
calculate how much drug to use in relation to the individual's size
and body weight.
   
Once malignant cells have spread beyond their original location,
however, traditional chemotherapy is usually much less successful at
producing a cure. In an attempt to develop a treatment for these more
advanced cases, the researchers at Dana-Farber have been experimenting
with levels of antitumor agents that are much higher than those
normally prescribed. In Lehman's case, the treatment was to last four
days, and the amount given during each 24-hour period was supposed to
be barely shy of lethal. The physician in charge of figuring out her
daily dosage, whose identity has not been released, apparently made
the mistake of writing down the amount that should have been given
over the whole four-day period.
   
Still, all hospitals double-check the dosage of chemotherapy drugs
that are given to a patient - and Dana-Farber is no exception.
According to Gina Vild, a hospital spokeswoman, once the physician has
written the order, Dana-Farber's rules require two pharmacists to
verify it. "Pharmacist 1 is supposed to check it and, yes, is supposed
to make the calculations himself," she told Time. He then "gives it to
Pharmacist 2, who looks at it and checks it" before sending the drug
to the patient's room. When the order for Lehman came through, neither
pharmacist caught the mistake in dosage.
   
Even at the bedside, there was still a chance for someone to realize
that something had gone desperately wrong. Lehman's blood tests showed
abnormal readings, and her electrocardiogram indicated enormous
stresses on her heart. "She was vomiting sheets of tissue," her
husband Robert Distel told the Globe. "((The doctors)) said this was
the worst they had ever seen." But they considered Lehman's violent
reaction to be normal for such an aggressive treatment. All told, at
least five hospital staff members failed to figure out that their
therapy was killing her.
   
Dana-Farber has acknowledged full responsibility for Lehman's death,
as well as the permanent heart damage of another woman who managed to
survive an identical fourfold overdose. In addition to ordering an
exhaustive investigation, the hospital's top physician has mandated
additional precautions against such egregious mistakes. Staff members
have been reassigned, and the pharmacy's computer program has been
modified so that drugs cannot be dispensed over preset limits.
   
Unfortunately, as long as doctors are human, treatment blunders can
never be eliminated entirely. "With 4 million patients a day visiting
physicians, it's inevitable if inexcusable that mistakes will be
made," says Dr. James Todd of the American Medical Association. Three
large studies over the past 30 years have documented a distressingly
consistent rate of medical mishaps in the U.S. By one measure, such
negligence in American hospitals may result in 80,000 deaths each year.
   
That toll is a sign to some critics that improvement is needed in the
systems that hospitals use to catch errors and review doctors'
performance. "You would not walk on an airplane if you did not know
that there are safety checks and backups and backups of the backups,"
says Dr. Sidney Wolfe, head of the Health Research Group. Hospitals
need just as many fail-safe mechanisms, he says, "so that even if one
or two fail, the third one catches the mistake."
   
In some fatal cases, it is hard to know if malpractice was involved.
Even the most routine procedures can go awry, whether or not doctors
are at fault. New York City was stunned last week by the news that a
four-year-old girl had died following a tonsillectomy, an operation
that is almost never deadly. Like 100,000 other Americans each year,
Desiree Wade was sent home a few hours after the surgery, which was
performed at St. Luke's hospital in Manhattan. She developed a fever
and became increasingly sick. Her coughs apparently tore open the
surgical wounds in her throat, and she bled to death. There is no
evidence that the surgeon did anything wrong, but state health
officials are investigating whether the child received the proper
follow-up care.
   
If a tonsillectomy can go bad, imagine all the things that can happen
with a bone-marrow transplant, a coronary-bypass operation or an
experiment in gene therapy. As medicine has become more complex and
the pace of technological change has accelerated, the opportunities
for error have multiplied. And when doctors are constantly testing new
treatments, as they are at Dana-Farber, they cannot fall back on years
of experience.
   
Factor in the new pressure to control costs, and doctors are in a real
bind. The medical profession sees increased danger in the new era of
managed care, in which hospitals and clinics must treat more patients
more quickly with smaller staffs. "In the rush for cost containment,
the caliber of the health-care team may be decreasing," warns the
A.M.A.'s Todd.
   
The challenge ahead will be to deliver care at a reasonable price
without compromising safety. Perhaps the only benefit of highly
publicized cases like Betsy Lehman's is that they will spur hospitals
to strengthen the safeguards needed to keep such tragedies as uncommon
as possible.
   
[The Disturbing Case of the Cure That Killed the Patient, Christine
Gorman, Time April 3, 1995; reported by Lawrence Mondi and Alice
Park/New York and Rod Paul/Boston]
   
CURE Comment: While, as patient advocates, we heartily concur that
              improvements in the quality of medical care is needed,
              e.g., more reasonable schedules for medical residents,
              we would also note that with the cancerous growth of
              managed-NONcare, this is not the time to strip patients
              and their families of the protections of malpractice
              laws under the guise of "tort reform."

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