There's a truly frightening aspect to the recent wave of hospital errors resulting in deaths and injury to patients. It's that the errors being committed are fairly elementary. And, furthermore, they're happening at so-called prestigious institutions that offer an implied-if not an explicit-pledge to adhere to the highest standards of quality.
In the most recent instance, a 41-year-old Illinois man died after he was given four times the prescribed dose of anti-cancer drugs during a five-day period in May. The University of Chicago Hospitals, which has a reputation as a premier medical facility, seemed to think it was enough to say it followed all the processes that should have been followed and to attribute the tragic case to "human error." But such a defense is clearly inadequate when death is involved.
The case was eerily similar to the death of a journalist from an overdose of medication at Dana-Farber Cancer Institute in Boston, a place usually described in both the consumer and trade press by the designation, "prestigious Dana-Farber."
Both deaths occurred amid heightened public concern resulting from the amputation of a wrong foot at a Florida hospital.
At Dana-Farber, a state investigation revealed shocking slip-ups that should have been uncovered by effective implementation and oversight of highly detailed treatment policies and protocols. Among the errors: pharmacists failing to compare the medical orders against two previous cycles of the same drugs in the same manner, a routine check that would have immediately flagged the much higher dose. Also, nurses were not responsible for checking out the accuracy of the dosage before administering medication.
Dana-Farber is implementing new safeguards for proper medication dispensing, including a high-dose warning system on pharmacy computers. The University of Chicago's chief executive officer says his facility is redoubling efforts to verify medication orders, but the Dana-Farber case should have served as a red flag to take such a step before tragedy occurred.
With the spotlight on medical quality, any institution that hasn't undertaken a review of its medical/surgical and medication procedures is just plain foolish. And while they're at it, executives ought to evaluate how best to explain their treatment protocols to a public and media increasingly savvy about medical quality matters.