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Massachusetts Board action will hurt patients

From the January 13, 1998 issue

More than four years after the 1994 medication error at the Dana Farber Cancer Institute, 22 practitioners have been punished or still face disciplinary action from the Massachusetts Boards of Registration for their role in the event. In 1997, the pharmacy board reprimanded three pharmacists for their role in the CYTOXAN (cyclophosphamide) overdose. In November 1998, the physician who wrote the order incorrectly had the right to renew his license suspended for three years by the medical board. Now, the nursing board is following the medical and pharmacy boards' misguided example by punishing the 18 nurses for their role in the error. Two nurses have accepted the Board's sanction of one year's probation and rigorous chemotherapy retraining. For the other 16, a disciplinary hearing is planned which could result in sanctions ranging from licensure revocation to reprimand.

The state health department, JC and Dana Farber administration acknowledge that the tragic error was caused by multiple weaknesses in the system. Still, it appears that the Massachusetts licensing boards believe their responsibility to promote safe professional practice is best achieved by disciplining the practitioners. However, this philosophy, akin to "what we need here is a bigger hammer," is seriously flawed. A punitive focus on individuals involved in medical error is dangerous. It inhibits open discussion about errors, creates a defensive and reactive environment, and hinders careful and unbiased consideration of the system-based root causes of errors. Health care systems are further weakened, especially if the sole responsibility for safe medical practices rests upon individuals, rather than strong systems that make it difficult for practitioners to make errors.

Furthermore, the boards, in their misguided efforts to hold these practitioners individually accountable for the medication error, send the wrong message about both individual and professional accountability. Their actions imply that practitioners should be held individually accountable for adhering to an unrealistic (impossible) standard of perfection - total absence of errors. Their action also suggests that those in authority are held professionally accountable to punish individuals who deviate from this standard. However, a non-punitive approach to errors does not diminish either individual or professional accountability for patient safety. Rather, it directs accountability in a productive and realistic manner. Individuals should be held accountable for reporting potential and actual errors that are detected, analyzing root causes of errors, and recommending system-wide changes. To support individual accountability, authorities (administrative staff and regulatory, accrediting and licensing agencies) should be held professionally accountable for promoting a culture of safety where errors can be openly reported and analyzed, and recommendations for system improvements are given high priority and are well supported.

In the wake of the error, Dana Farber management reacted accountably. The medication system was extensively redesigned to minimize the possibility of chemotherapy errors and, in order to help other institutions improve safety, staff have openly discussed the changes at professional forums throughout the U.S. Rather than punishing these nurses, a far better course of action would be for the Massachusetts Board of Registration in Nursing to begin visiting acute care hospitals within their jurisdiction to assure patients that similar safety measures exist to protect them from another tragedy.

If you would like to express your opinion regarding the board's action, please mail, fax or phone your comments to Theresa Bonanno, RN, Executive Director, Massachusetts Board of Registration in Nursing, Leveret Saltonstall Building, 100 Cambridge Street, Room 1519, Boston, MA, 02202, phone: 617-727-9961, fax: 617-727-2197.

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