Editorial The Multidisciplinary TeamPartners in Patient Safety

A basic principle of Cancer Practice’s mission is thatthe multidisciplinary team is critical to the care of

patients and families. It is the belief of Cancer Practicethat greater collaboration is achieved and cooperation isenhanced when each discipline understands the roles,functions, and responsibilities of the other health profes-sionals involved in patient care.

Nowhere is the need for effective functioning of theteam more imperative than in the area of patient safety.In 1994 and 1995, the oncology world was shaken assubstantial errors resulted in patients either dying or be-ing seriously impaired. Misadministration of chemo-therapy at the Dana Farber Cancer Institute in Boston andat the University of Chicago Hospitals, plus surgery onthe wrong side of a patient’s brain at Memorial Sloan-Kettering Cancer Center in New York City, promptedreview of policies and procedures across the nation.From these incredible tragedies came significant improve-ments in care processes and delivery systems. The oncol-ogy community went forward, sadder but wiser.

In the process of drawing good from these experi-ences, a special leadership role was taken by the DanaFarber Cancer Institute. Internal review processes werestrengthened to complement external assessments. Inves-tigators of the incidents focused on the physicians whowrote the incorrect order and the pharmacists who filledit. The respective boards governing the practice of medi-cine and pharmacy in Massachusetts suspended the li-cense of the doctor involved and formally reprimandedthe pharmacists. In part because the nurses had followedestablished policies related to chemotherapy administra-tion, two separate external assessments confirmed nofault with individual nurses involved in the overdoses.

The Massachusetts Board of Registration in Nursinglooked at the situation differently. Early this year, close to5 years after the event, the Board decided to take actionagainst the 18 nurses who were involved in the over-doses. There has been intense and varied reaction to thisdecision, judged by many to be controversial, by some aspunitive, by others as an appropriate indication that notjust one, but all disciplines failed in their responsibilities.

Two key factors appear to be that the Board main-tains that a license to practice nursing mandates account-ability for patient safety apart from the accountability ofother professionals. The nurse is viewed as the last safe-guard for the patient before chemotherapy is adminis-tered. A second important point relates to the availabilityof national standards. In this case, the standards of theOncology Nursing Society called for a check of the pa-tient’s protocol before chemotherapy administration. Atthe time, this was not the standard to which the nurseswere held. The Board suggested that the higher nationalstandard should have guided the nurses’ practices.

The issues raised by the Board’s decision are of pro-found importance to the multidisciplinary team. Deficien-cies in processes related to chemotherapy administrationstill exist. There are institutions in which the patient’sprotocol is not available for verification of chemotherapy,where changes in protocols are not communicated in asystematic fashion, where chemotherapy administration isnot the focus of continual process improvement activi-ties. These gaps in patient safety are the responsibility ofthe entire team. Each discipline involved must redoubleefforts to deal with these deficiencies.

The debate about the Massachusetts situation has alsoallowed issues about how errors are handled in the clini-cal arena to resurface. There is, of course, a concernabout rigid systems that invite underreporting of errors.There is a serious and widespread lack of awarenessabout how studying errors that are caught before reach-ing the patient can significantly contribute to earlier iden-tification of malfunctioning or inadequate systems. Sadly,there is also a small minority who are more concernedabout staff relationships than about patient safety. Puttingthe focus clearly on the patient is essential.

No one selects oncology as a practice specialty tocause harm. The altruism and dedication of the health-care disciplines involved in oncology are exemplary. Yet,human beings will make mistakes. How do we build insystems to prevent individual errors? How do we safe-guard the patient when a nurse is overwhelmed by aheavy patient assignment, a pharmacist is filling orderswithout the proper electronic or physical documentsneeded for verification, a physician misplaces a decimalpoint, a secretary takes off an order incorrectly? How dowe teach all professionals that their discipline has a par-ticular and nontransferable accountability for practice?

The exemplary manner in which the Dana FarberCancer Institute has used quality improvement principlesand techniques to create substantive change in patientprocesses provides a model for all of oncology. On a per-sonal level, our deepest sympathy goes out to the pa-tients and families affected and then to the staff membersinvolved. On a professional level, we look with admira-tion to an institution that has been in the eye of thestorm and used the experience to lead. May we all profitfrom their example.

108 CANCER PRACTICE May/June 1999, Vol. 7, No. 3© American Cancer Society 1065-4704/99/$14.00/108 108