Medical errors in treatment of breast cancer

1. 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.

2. 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

3. 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

4. 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

5. Error in mammography Age 20 year with cyclical mastalgia Mammogram taken in a “big” hospital

6. Error in skin incision

7. 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

8. Error in breast conserving surgery • Surgery Referred Surg. Oncol. • Lumpectomy 51 -- • WE 07 -- • SM+AC 20 80 • PM/RM 20 171 • _______________________________ 98 251

9. Bad treatment

10. Bad treatment cont……..

11. 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% Error in prescription of tamoxifen (152 patients)

12. 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 Who makes medical error:

13. 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 Types of errors

14. Error prevention in breast cancer treatment • Physician • Treatments • Patients • Technology • Adverse medical outcomes vs. carelessness on the part of patients or physicians

15. 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 Public perception of error

16. Prevalent times Fisher Halsted

17. 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

18. 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

19. 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 Frequency of errors

20. 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 Strategies to reduce error METACOGNITION: observation and analysis of one’s own activity

21. 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

22. System approaches to breast cancer treatment • Resource requirement • Cost effectiveness • Risk benefit ratio • Decision making processes • Emergence of guidelines?

23. 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

24. Salvage bad incision

25. Bad apples Negligence Errors in performance: Prevention, diagnosis, treatment Training Prevention of errors

26. Preventable error