A highly publicized, fatal chemotherapy overdose that killed a Boston Globe reporter at Boston's Dana-Farber Cancer Institute has driven striking cultural changes and a system overhaul. A physician order entry system now eliminates many communication problems. The system automatically searches a patient's record looking for possible drug interactions and automatically updates protocols so that staff can see those that are current. If a pharmacist intervenes to change a physician order, the system records it. It points out that while the current legal climate doesn't encourage reporting, research shows that motivation for lawsuits arises from poor communication, a breakdown in trust, and a desire for revenge.
Communication is Key.
During a Feb. 23 talk at a Washington conference sponsored by the Institute for Healthcare Improvement and the National Coalition on Health Care, he said newsletters were instrumental in getting anesthesiologists to make safety a priority. More standardization within hospitals has made anesthesia machines safer, too. Pierce said that before the mid-1980s, different types of anesthesiology machinery placed in operating rooms within the same hospital created confusion. Today, there's still room for improvement, Pierce emphasized. IHI says participants will learn new ways to reduce common and lethal errors, work with high-risk drugs, and improve communication among physicians, nurses and pharmacists.