Altman, Lawrence K. "Committees Find Signs of Weak Leadership at Dana-Farber," New York


Altman, Lawrence K. "Committees Find Signs of Weak Leadership at Dana-Farber," New York
Times, 31 October 1995, p. C5.

(This article appears in its entirety.)

The Dana-Farber Cancer Institute in Boston said yesterday that two committees had concluded
that its top leadership was weak and that the quality assurance of its clinical care and training
were seriously flawed.

The institute appointed the panels to investigate its care after over-doses of drugs in an
experimental treatment for breast cancer killed one patient and left another with severe heart
damage a year ago. The overdoses were given in November 1994 but the errors were not
discovered until February. The patient who died was Betsy Lehman, 39, a health columnist for
The Boston Globe.

To improve patient safety, Dana-Farber officials said they had made 39 changes in procedures
and personnel in accordance with the committees' recommendations. In recent months, the
institute has named a new president, Dr. David Nathan, who replaced Christopher Walsh, and a
new chief of staff, Dr. Stephan Sallan, who replaced Dr. David M. Livingston.

Last spring Dana-Farber, a Harvard teaching hospital, was put on probation after a surprise
inspection by the country's leading agency for certifying hospital quality, the Joint Commission
on the Accreditation of Healthcare Organizations. In a separate action, Federal health officials
cited a wide variety of serious deficiencies in patient care at Dana-Farber.

After reinspections, Dana-Farber is now in full compliance with state, Federal and Joint
Commission standards, the institute said. "If any good news can come out of something like this,
it is that it has led to sprucing up of systems and a greater appreciation of what is needed to make
sure things are safe," said Dr. Vincent DeVita, the head of the Yale Cancer Center in New
Haven, who was chairman of one of the committees.

Dana-Farber issued a summary statement of the panels' reports because Massachusetts law
protects the confidentiality of their reports, the names of doctors and others involved in the
investigation, and some doctors and pharmacists involved in the overdose are under investigation
by Massachusetts officials.

The committees found no evidence of any cover-up within the hospital and said that their
findings were identical to those previously made public by Dana-Farber. Both panels said Dana-
Farber "had not sufficiently valued clinical experience when it last selected its most senior
leadership" and recommended that the clinical leadership be substantially strengthened." In
appointing Dr. Sallan, a pediatric oncologist, as chief of staff, Dana-Farber has charged him with
responsibility for establishing and monitoring the institute's standards of clinical care.

The institute's quality assurance program was criticized as seriously deficient because of unclear
lines of responsibility. Dana-Farber said it had created a system of quality assurance teams.
Dana-Farber said it had changed its system of reviewing the design of scientific blueprints that
control the conduct of research studies like those in which the overdoses were given.

The committees said the structure and supervision of the program to train cancer specialists
needed to be redefined and improved, and responsibility for the program needed to be clearly
delineated. Doctors in training as specialists, known as fellows, often give much of the care in
teaching hospitals like Dana-Farber. In a new move, Dana-Farber now provides regular feedback
to fellows.

Each fellow is now assigned a supervisor and is given a monthly evaluation, Dana-Farber said.
Dana-Farber now requires an attending doctor to co-sign all orders and prescriptions for anti-
cancer drugs that are written by fellows.

One doctor wrote the overdose orders on both patients and he has been relieved of
responsibilities for patient care. He is also the subject of a disciplinary procedure at the hospital.
n addition, Dana-Farber has reprimanded the oncologist who was the principal investigator of the
experimental study. It found that she bore partial responsibility for the over-doses because the
manner in which she investigated the incidents contributed to the delay in detecting the problem.
Specifically, the report said, she had not checked the written chemotherapy order with the
protocol to determine whether there had been an overdose. She is now undergoing retraining.

Dana-Farber has installed computer programs designed to check the amounts of drugs doctors
order and to alert pharmacists about orders that exceed preimposed dosage limitations.

Both committees found deficiencies in the structures of policies of the nursing department and
Dana-Farber has appointed a new heard of nursing who reports directly to the head of the
institute. Among other changes, nurses are now included in programs to educate staff members
about new experimental studies, and schedules allow greater continuity of nursing care for each