Chemo Overdose Overview

     Of all the people in the world, Betsy Lehman was the least likely to be the victim of a medical mishap. As a respected health journalist for the Boston Globe, Lehman took a keen interest in patient care issues. Of particular concern to Lehman was the patient’s personal role in treatment and the benefit of communication between the patient and the healthcare team. When breast cancer struck, she actively engaged in her treatment, journaling her experience in her column and inspiring readers with her brave, intelligent response to cancer. She understood that patients need to take an active role in treatment and ask plenty of questions, advice she followed faithfully during her own harrowing experience. When cancer reappeared in her lymph nodes, Lehman opted for an aggressive, experimental treatment at prestigious Dana-Farber, part of the Harvard Medical School. She and four other patients participated in a protocol, which called for three cycles of high-dose cytoxin before re-infusion of stem cells previously extracted from their bodies. Cytoxin is a familiar chemotherapy drug with known heart toxicity. Patients One and Four experienced no ill effects from the treatment but two and three received massive overdoses four times the recommended dose. Patient Two, Betsy Lehman, died two weeks later. Patient Three survived with a ravaged heart. Lehman’s autopsy revealed her cancer was cured.

     The cause of Lehman’s death were not understood until two months later when a data entry employee noticed the irregularities in the dosage: a quadruple overdose. Lehman and her husband, a scientist at Dana-Farber, knew something was dreadfully wrong with her reaction to the treatment yet their efforts to discuss this with the medical team were not taken seriously. The active role Lehman advocated failed. If the overdose had been detected quickly, Lehman, like Patient Three, could have survived. As it was, she died while preparing to be discharged, despite an abnormal EKG, swelling, vomiting, and abnormal blood tests. Her medical team ignored the warnings. In the aftermath, it became clear that three pharmacists, seven nurses and two physicians failed to detect a dangerous dose prescribed by a 2nd year Oncology Fellow. The pharmacists and physicians were misled by ambiguous wording on the summary sheet of the protocol, the source of information generally relied upon as a shortcut. Nurses at Dana-Farber were not responsible for verifying drug doses or determining accuracy. This is a research hospital where nurses were not equal members in the treatment team. Also, it was not customary for supervising physicians to countersign junior physician’s orders.

     Observations of the protocol data focused on the data of the cytoxin active breakdown product, not the parent drug being infused. This narrow knowledge of her treatment, compounded by the team’s disregard to her abnormal EKG, her physical response to treatment, including severe vomiting, and the repeated complaints by Lehman and her husband of her excessive suffering, contributed to the error going undetected. Dana-Farber, in classic tombstone behavior, has now addressed issues that were previously ignored, elevating the status of nurses, adopting feedback mechanisms to determine if errors have occurred, and requiring cross-checking between pharmacy and physician and supervising physician review of orders.