Medical errors in treatment of breast cancer

HS ShuklaProfessor and HOD

Department of Surgical OncologyIMS, BHU

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What is medical error?“To err is human”

• Failure due to some identifiable personal fault

• Interpretation is that harm is done by carelessness or intent

• There is a complex system that determines if failure is due to an error

Core element of error is failure:Goal is set attempt fails

• Contextual element of error: The person and equipment were capable to achieve success by an effective action failed

• Error goal not achieved• Mistake best course of action not adopted• Slip or lapse failure to successfully execute an

action• Violation course of action considered

mandatory not taken to achieve goal

Transformation• Medical care: comforting the ill

• Is now economic, scientific, political, and cultural system

• Failure to achieve expected goal is perceived as an error

• Error of commission and omission crepe in as the course of action becomes well defined

Error in mammography

Age

20 year with cyclical

mastalgia

Mammogram taken in a

“big” hospital

Error in skin incision

Error in breast conserving surgery is because system does not support it

• Ground reality does not support it

• Mega-voltage 200/ 1500

• Radiation Oncology 800/ 2500

• Physicist 500/ 1500

• Technologists 1000/ 3000

Error in breast conserving surgery

• Surgery Referred Surg. Oncol.

• Lumpectomy 51 --

• WE 07 --

• SM+AC 20 80

• PM/RM 20 171

• _______________________________98

251

Bad treatment

Bad treatment cont……..

Error in prescription of tamoxifen (152 patients)

• 100% received Tmx

• 6 months• One year • 2 years

• Under treatment 100%

• ER+, PR+: 11.6%• ER+, PR-: 13.3%• ER-, PR+: 16.07%

• ER-, PR-: 58.93%

• Over treatment 58.93%

Who makes medical error:

• Incompetent • Competent• Largest % of all

medical errors• All clinicians make

misjudgment harming the interest of the patient, in all branches of medicine

• Development of team approach

Types of errors

• Iatrogenic errors: latent or fatal

• Accidental errors: latent or fatal

• Intentional errors: purposeful to cause injury

• Preventable or non-preventable errors

• Human error:– Skill based:

inadequate training to complete a task

– Rule based: Deviation from well defined protocols

– Knowledge based: Performance of surgical procedure without adequate information

Error prevention in breast cancer treatment

• Physician• Treatments• Patients• Technology • Adverse medical outcomes vs.

carelessness on the part of patients or physicians

Public perception of error

• Medical care has changed from a matter of privilege to the position of right

• Adjustment with explosion of advances medical/technical, drugs related, patient mobility, information availability

• Business interest• Political interest• Financial gains• All combined have

changed the composition, behavior, perceptions, and expectations of public consciousness related to medical care

Prevalent times

Fisher Halsted

Errors with national guidelines

• Screening not effective• Treatment strategies not supported by

scientific data• Recommended follow-up testing does not

translate in survival advantage• TNM survival statistics gives a biased

picture of disease status in a patient

Result of errors in guidelines

• Public has inflated expectations of the effectiveness of treatment

• Clinician is locked into screening, treatment and follow-up protocols with intrinsic limitations

• Clinician get set-up for wide variety of court actions- breast cancer is most common malpractice litigation

Frequency of errors

• 1 in 10,000 or 100,000 decisions made in the USA (James Reason 1999)

• 44,000-98,000 die each year due to medical error

• BMJ 2000: 8 patients injured and 1 die in every 30mts due to medical error

• Errors in breast cancer treatment can be minimized at present

Strategies to reduce error• Sub/super

specialization• Morbidity and

mortality audits• CME• Publication of

surgeon and hospital outcomes

• Increasing litigious environment

• Systems approach such as in airlines industry

• High risk areas: anesthesia, pathology, surgery, pharmacy, cancer

METACOGNITION: observation and analysis of one’s own activity

Care is improved and mistakes reduced by computer

• Robotic hip replacement is error free!

• Is medical error leading to harm to the patient of breast cancer rare? Far from it

System approaches to breast cancer treatment

• Resource requirement• Cost effectiveness• Risk benefit ratio• Decision making processes• Emergence of guidelines?

Salvage

• Results are assessed with respect to overall effects

• Errors: Jenner's cowpox

• Iatrogenic, accidental, Euthanasia?

• Medical errors are not “wrongs, weaknesses or failure” but are outcomes from “inevitable, relentless, obligatory change that is not preventable or predictable”

Salvage bad incision

Prevention of errors

• Bad apples

• Negligence

• Errors in performance: Prevention, diagnosis, treatment

• Training

Preventable error