I was gobsmacked when I heard this on the local news today. A patient at San Mateo Medical Center (San Mateo is the small county immediately south of San Francisco and north of Silicon Valley/San Jose) died after being given 10 times the correct chemotherapy dose. We all know that medical errors are a problem that still exists, but this error was exactly the same as that which killed Betsy Lehman, the health columnist of the Boston Globe at Dana Farber cancer center in 1994. Betsy’s death was part of the groundswell that ended up 5 years later in the IOM “to Err is Human” report.

Nearly five years after the report and ten years after the tragedy in Boston, it’s clear that this is still a frequent occurrence. San Mateo Medical Center will hold an enquiry, but it’s almost certain that a miscommunication between the nursing, medical and pharmacy staff, without adequate process or technology back-up systems, is to blame. And there’s been plenty of time for the health care system to call attention to that, but as Michael Millenson says it’s mostly been silence.