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COPYRIGHT 2004 The Boston Globe
Byline: Scott Allen
Nov. 30--Nurse Teresa Mazeika has known the woman knitting in the blue reclining chair for months. But she asks Carolyn Harlow her name and birthday anyway, as she approaches with chemotherapy for Harlow's blood cancer. Mazeika, a 17-year nursing veteran at Dana-Farber Cancer Institute, isn't taking any chances that she is about to give the drug to the wrong patient.
The name game is just one in a string of rituals Mazeika goes through before Harlow can have an injection that lasts all of five seconds: She reviews Harlow's treatment instructions on a computer to be sure the patient is getting the correct medicine; she checks the drug's concentration to be sure it's right for Harlow's size; she informs the pharmacist that Harlow shows no signs of side effects from previous treatments.
The abundance of caution is born of a hard lesson: 10 years ago, one patient died and another suffered irreversible heart damage at the Dana-Farber because the staff wasn't cautious enough. A young doctor accidentally prescribed four times the intended dose of breast cancer medication to Boston Globe health columnist Betsy Lehman and teacher Maureen Bateman, but none of the roughly 25 medical staff involved in their care noticed until weeks later.
"It was a pretty public humiliation," recalled Dana-Farber nurse Judith Prisby, expressing a view held by many staff members at the time. "My whole world changed in an instant."
A decade after Lehman's death, on Dec. 3, 1994, Dana-Farber has emerged as one of the most safety-conscious hospitals in America, with computers that trigger alarms at potential overdoses, a hypervigilant error-reporting system, and...
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