Medical Errors in Cancer
Medical errors have been defined as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” Harmful medical errors are adverse events caused by medical errors. Attention to medical error has increased in recent years in medicine and oncology, building in good part on the 1995 Institute of Medicine (IOM) Report “To Err is Human,” which brought to the forefront of medicine the high incidence and healthcare consequences of errors that occur both in and outside of hospitals. Researchers have studied the incidence of medical errors and estimated the numbers of injuries and deaths they cause. Patients and advocates are demanding greater safeguards against errors. Physicians and institutions have invested time and resources in patient safety training, procedures aimed at preventing errors, and efforts to change a culture of blaming and shaming physicians that yielded mainly denial, hiding, or the spreading of blame in the case of medical error. In addition, medicine and medical institutions have adopted ethical mandates to report errors and adverse events and disclose them to patients and family members, together with apologies.
Research, educational, and programmatic efforts in oncology have been directed toward the prevention of errors through systemic improvements and new technology such as computerized tools for ordering different types of cancer therapies. Particular attention has been paid, in oncology as in other areas of medicine, to errors in one part of a complex system of care – a physician’s dosage error in prescribing a medication that is then sent to the hospital pharmacy, leading medication to the hospital pharmacy, leading, finally, to the administration of an incorrect dose to the patient. Another important area of research and practice is the accountability of medical teams balanced with the responsibility of individual team members. Attention to the early aftermath of error, including the impact of physician disclosure or nondisclosure on patients and family member decisions on whether or not to pursue malpractice lawsuits, has also increased.
Research has been conducted on physicians’ emotional responses to error, and a number of narrative accounts supplement these studies; although, unfortunately, few of either in the field of oncology. The lived experience of committing or witnessing a medical error and the emotional–psychological difficulties associated with it are of major concern as we shift from a culture of singling out individuals involved in the commission of errors as incompetent or even morally deficient, to one in which we acknowledge the inevitability of medical errors while striving to limit their incidence. There is also a need to consider the role of mental health professionals in helping oncology professionals to face their medical errors and respond appropriately to patients and family members when these occur.
Prevention and reduction of medical errors requires both system change and increased individual awareness and alertness. Patient safety is not an abstract concept referring to the universal category of “patients,” but a concrete praxis involving each cancer patient who has entrusted physicians with his or her medical care. The centrality of the patient in every clinical encounter and act requires our clinical competence, communication skills, and commitment to provide the best cancer care with expertise, humanity, and humility. By contrast, arrogance can be a major component of medical error and is one attitude that patients often associate with errors that they personally suffered.
In 1980, Dr. Franz Ingelfinger wrote of his experience as a cancer patient facing the dilemma of what prophylactic treatment to have after surgery for an adenocarcinoma of the gastro-esophageal junction. He described the contradictory advice he received from well intentioned colleagues and friends as making him and his “wife, son and daughter-in-law (both doctors) increasingly confused and emotionally distraught.” Those feelings were finally alleviated when “one wise physician friend said, ‘What you need is a doctor.’” Dr. Ingelfinger concluded that “a physician can be beneficially arrogant, or he can be destructively arrogant.”
While he called “beneficially arrogant” those physicians who take charge of their patients and do not to shy away from assuming their professional responsibilities in front of difficult treatment choices, Dr. Ingelfinger wrote at a time when the field of oncology was less well developed and sophisticated than at present, and many cancer patients were still ill-informed of their diagnosis and prognosis and not true partners in their own care. As Dr. Allan Berger writes, physician arrogance is, however, regrettably still common and “violates the benevolent spirit of medicine—its very soul—as well as the quality of medical care.”
Ref: Antonella Surbone and Michael Rowe, Clinical oncology and error reduction, John Wiley, 2015
