E-prescribing first step to improved safety.

Change doesn't come without pain, but the suffering caused by medication errors is justifi ca-tion enough to embark on the type of sweeping institutional reforms called for by an Institute of Medicine panel, several experts said. Electronic prescribing, electronic health records, and computerized treatment protocols are indispensable tools for reducing medication errors, according to the IOM report called Preventing Medication Errors. But successfully incorporating these tools into practice requires strong leadership and a commitment to an often diffi cult culture change, said physicians and cancer professionals who have been through the process. The landmark report found that there is one avoidable medication error per hospitalized patient per day; more than half a million errors occur each year among Medicare patients alone. The report cites some noteworthy progress in patient safety, but it concludes that too often these efforts don't come about until an institution experiences a mistake that causes patient harm or even death. Although medication errors may be no more common among cancer patients , the report's authors noted that the toxic effects of chemotherapy means that mistakes can be more severe in oncology. However, it is also often diffi cult to distinguish between the expected toxic reaction to cancer drugs and unnecessary suffering due to incorrect doses or improper administration, they said. In 1994, Betsy Lehman received a fatal overdose of the chemotherapy drug cyclophosphamide, which is just an example " of the failure of the care delivery system to catch and mitigate a medication error, " according to the IOM report. While being treated for breast cancer as part of a clinical trial, Lehman was accidentally prescribed 4,000 mg/m 2 a day for 4 days instead of the appropriate dosage of 4,000 mg/m 2 spread over 4 days, a mistake that wasn't discovered until 10 weeks after she died. For the Dana-Farber Cancer Institute, where Lehman was being treated, the accident sparked an immediate push to improve the institute's patient safety measures , said Saul Weingart , M.D., Ph.D., director of the center for patient safety at Dana-Farber. " The institute had always had an interest in providing safe care, but that was a wake-up call, " he said. That wake-up call soon led to changes in the way Dana-Farber protects patients. But even more important than the immediate reaction was the challenge of sustaining the effort over the long term, a job that fell to a …