Medical errors in treatment of breast cancer HS Shukla Professor and HOD Department of Surgical Oncology IMS, BHU These PowerPoint presentations are free to download only for academic 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 SurgeryReferredSurg. Oncol. Lumpectomy51-- WE07-- SM+AC2080 PM/RM _______________________________ 98251

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: IncompetentCompetent 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 FisherHalsted

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