Download Medical errors in treatment of breast cancer

Medical errors in treatment of
breast cancer
HS Shukla
Professor and HOD
Department of Surgical Oncology
IMS, BHU
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purposes, with due acknowledgements to authors and this website.
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 nonpreventable 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
• Errors in breast
100,000 decisions
cancer treatment can
made in the USA
be minimized at
(James Reason 1999)
present
• 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
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