A 'SAD DAY' AT FAMED HOSPITAL
by Robert Cooke

Betsy Lehman was no stranger to modern medicine. As a health columnist of The Boston Globe she knew her way around doctors, hospitals and the arcane language of treatments and care. And her husband, Robert Distel, was a scientist at the famed Dana-Farber Cancer Institute in Boston.

But none of that could save her from gross medical error.

During a marrow transplant procedure for breast cancer at Dana-Farber in November, Lehman got a chemotherapy overdose so massive it killed her. Another patient, a 52 year old woman being treated the same week by the same team, got a similar overdose, four times greater than the maximum. Though still alive, she is 'chronically debilitated', Dana-Farber doctors say.

The errors, revealed yesterday in The Boston Globe, did not come to light until two months after Lehman died, when an assistant data manager noticed the high doses in institute records of ongoing research projects. So the fatal error - apparently first made by a research fellow who filled out the medication order - was missed by at least a dozen medical specialists at one of the nation's finest hospitals, even though Lehman showed warning symptoms that accompanied her decline into death on December 3rd. And nothing was noted during Lehman's routine autopsy - which found no signs that breast cancer still lingered in her body.

The cancer centre, which is affiliated with Harvard University, said human error was the only explanation. "We accept absolutely full responsibility for these tragedies," Dana-Farber physician-in-chief Dr David Livingston said yesterday. "It's as sad a day as I can remember in the history of this institute."

According to the Globe report, a special computer system will be installed at the Dana-Farber Institute to track dosages and sound an immediate alarm if anyone prescribes more than the maximum safe dosage of a medication. Many other cancer centres, such as Memorial-Sloan Kettering in Manhattan, have such systems,

"Our pharmaceutical department inputs all of our medicines on the computer," said Lynne Taylor, a Memorial-Sloan Kettering representative. "If the dosage requested is outside the normal range, the computer alerts you and says 'Are you sure you want to do this?"

In the cases at Dana-Farber, a team of outside experts - led by Dr Vincent DeVita, former head of the National Cancer Institute - will investigate. "We will track every step" of the medication process that was followed at Dana-Farber, DeVita said, "to see if they require additional mechanisms" to prevent such accidents. "They are a very good institution, and we'll just try to make it better."

An internal investigation also is under way, and Dana-Farber is negotiating a settlement with Lehman's family. She was the mother of daughters 3 and 7.
(Ridgley Ochs contributed to this story.)

CTM Comment: The above story is the tip of the iceberg for chemotherapy and radiation deaths, and serves to remind us how far medicine has strayed from the days of Hippocrates' "first do no harm to the body…" Perhaps of even more concern is the willingness of the medical establishment to 'take full responsibility' for deaths like these, knowing that families face an up-hill struggle to get accountability from the medical profession, which is largely immune from prosecution on the thousands of iatrogenic deaths that plague medicine each year. For accountability and responsibility once again to become part of medicine, a return to the sound building blocks of health, such as nutrition and prevention, must become the focus of all our efforts.