Chemo Overdose Analysis

     Safety is the product of a team, not the individual. Staff needs to be able to question across authority boundaries in order to “see” the work of others. Silo mentality restricts the ability to work cooperatively among disciplines. Recurring patterns in human error can be addressed through enhancing teamwork where missing expertise can be completed, hidden assumptions identified. Fixation on the plan of treatment can be set straight by a fresh perspective. Division of responsibility and authority can cloud understanding. Double binds put workers in a lose-lose situation, which occurs when people are responsible for outcomes but lack authority. Tunnel vision confines practitioners to accurate but possibly incomplete knowledge; improved communication through teamwork helps us see the big picture. Covert work practices can develop as ways to get work done outside written policies. Teamwork enhances safety when we rely on the expertise of other and learn from their experiences.

In the Betsy Lehman chemotherapy overdose the following flaws in teamwork led to her death:

• Information about the chemotherapy overdose of another patient in the trial (involving four patients) was not communicated.
• Patient and family complaints about unusual and extreme side effects to treatment were ignored; they were not treated as member of the healthcare team.
• Attending did not review the chart per Dana Farber culture.
• Nurses did not have the responsibility to verify drug doses in protocol.
• Summary sheet synopsis of treatment was confusing.
• Fixation on plan of treatment led to ignoring evidence of error.