Nurses face 'unwarranted' sanctions
Overdoses led to death, but doctors' orders were followed.
BOSTON - Eighteen nurses have been punished or face punishment for following doctors' orders in giving chemotherapy overdoses to two patients in 1994, one of whom died as a result.
The state nursing registration board is pursuing sanctions against the nurses at the renowned Dana-Farber Cancer Institute - even though the state health department, a national hospital accrediting agenc the hospital's own investigation team said the nurses didn't do anything wrong.
"We believe the Board of Registration in Nursing's decision in this case is inappropriate and unwarranted," Dana-Farber's president, Dr. David G. Nathan, and chief of nursing, Susan Grant, said Tuesday in a prepared statement.
Critics of the decision said the hospital's complicated system for prescribing chemotherapy was to blame, not the nurses.
"What we had was a terrible tragedy caused by lousy systems," said Dr. Lucian Leape, a medical doctor at the Harvard School of Public Health.
"They really had a bad system and they did something about it," he said, noting Dana-Farber's efforts to revamp its system have been "exemplary."
"The nurses were merely pawns in this game," said Leape.
But following doctors' orders and established procedures wasn't enough to meet the minimum standard of care for nursing, said Theresa Bonanno, the nursing board's executive director.
"Apparently the system in place at the time didn't require the nurses to double-check, but I think if the nurses made an effort to check, were interested in checking or even questioned the dose, that wouldn't have happened," she said.
Two of the 18 nurses cited by the state board have signed consent agreements to accept probation for one year and to undergo additional training. The other 16 face disciplinary hearings and could lose their livelihoods.
Leape, who has advised more than 60 hospitals on establishing more foolproof systems for patient care, said the decision is a setback for patient safety.