Medical errors in treatment of breast cancer

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Medical errors in treatment of breast cancer

• HS Shukla
• Professor and HOD
• Department of Surgical Oncology
• IMS, 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

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Core element of error is failureGoal 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

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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

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Error in mammography

• Age
• 20 year with cyclical
• mastalgia
• Mammogram taken in a
• big hospital

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Error in skin incision
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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

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Error in breast conserving surgery

• Surgery Referred Surg. Oncol.
• Lumpectomy 51 --
• WE 07 --
• SMAC 20 80
• PM/RM 20 171
• _______________________________
• 98 251

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Bad treatment
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Bad treatment cont..
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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

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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

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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

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Error prevention in breast cancer treatment

• Physician
• Treatments
• Patients
• Technology
• Adverse medical outcomes vs. carelessness on the
  part of patients or physicians

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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

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Prevalent times
Fisher
Halsted
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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

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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

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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

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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 ones
own activity
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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

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System approaches to breast cancer treatment

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

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Salvage

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

• Results are assessed with respect to overall
  effects
• Errors Jenner's cowpox
• Iatrogenic, accidental, Euthanasia?

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Salvage bad incision
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Prevention of errors

• Bad apples
• Negligence
• Errors in performance Prevention, diagnosis,
  treatment

• Training

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Preventable error