By Sharon F. McGee, MD, PhD

As in life, error in medicine is inevitable and ubiquitous. I am sure that on reading this article’s headline alone you can recall your own professional errors of varying degrees and outcomes. Despite its prevalence, health care professionals, particularly physicians, have a complex relationship with error. This may stem from the Hippocratic oath we pledge in the early days of our training, “First do no harm”—a noble mantra that can set us up for a failure that we can find hard to accept.

Medical error came to the forefront in 2000, when the U.S. Institute of Medicine (IOM) published the landmark report To Err Is Human: Building a Safer Health System.¹ Here medical errors were estimated to account for between 44,000 and 98,000 deaths each year. A more recent report estimated that more than 250,000 people in the United States die from medical errors, making it the third leading cause of death.² These numbers are astounding, and do not even capture medical errors that result in non-fatal harm, or in which harm is averted. Following their report, the IOM proposed a national agenda to reduce health care error and improve patient safety, with an emphasis on reviewing incidents to develop strategies for prevention. However, despite these efforts, medical error remains a significant issue requiring greater attention, and a more comprehensive approach.

Medical Errors 101

Error can be defined as failure of a planned action to be completed as intended (error of execution), or use of a wrong plan to achieve an aim (error of planning). Serious errors are those that result in death or permanent injury, while minor errors cause harm that is not life-threatening or permanent. Near misses are errors where harm was avoided either by chance or intervention.^1,3 Perceptions of what constitutes medical error can also vary, particularly for patients, who tend to take a broader view—for example, perceiving a physician’s failure to communicate effectively as a medical error.⁴

Errors in oncology, as in other specialties, can occur at various stages in the health care journey, from diagnosis to treatment. An abnormality is missed on a screening breast mammogram leading to delayed diagnosis. A pathology report incorrectly identifies the origin of a metastatic cancer leading to incorrect treatment decisions. A central venous catheter is placed for chemotherapy and results in a serious infection requiring hospitalization. A patient receives a chemotherapy dose that was not adequately reduced for impaired organ function leading to increased toxicity. Indeed, chemotherapy errors are among the most common errors in medical oncology, with a recent study reporting them at a rate of 1 to 4 per 1,000 orders, affecting at least 1% to 3% of patients with cancer.⁵

Many factors can contribute to error, and make it easier to arise. Patient factors include language barriers, poor socioeconomic status, multiple comorbidities, and increased health care contact. Fatigue and excessive workload can contribute to error for physicians, as well as inadequate supports or training. While it is the patient who is primarily affected by error, there can be equally significant impacts on the physician, hospital, and society at large, where the resulting harms may be physical, mental, emotional, legal, or professional.

Our approach to error in medicine has largely focused on reviewing incidents with the aim of prevention. A common example of this is morbidity and mortality rounds, although larger-scale audits may also occur. The overall approach, however, is to review the incident, identify the contributing factors, and develop strategies to prevent future errors. While this is certainly very important, it is limited by the need for open reporting of error, which can be poor. Furthermore, it does not address how we respond to or recover from error, which are equally important.

Don't: Ignore, Deny, Defend

Unfortunately, our response to error in the medical profession is frequently poor, with a tendency to ignore, deny, or defend. While we may report errors to our hospital or legal/professional advisors, the patient may not be so readily informed. Indeed, studies have shown gaps between what physicians say they would disclose to patients in the event of an error, and what they actually disclose.⁶ This silence is not helpful for patients, or ultimately for the medical profession.⁷

In oncology we may also be at risk of minimizing errors in patients with advanced cancer. For example, a patient with advanced lung cancer and a life expectancy of less than 4 weeks is admitted for symptom control and receives sub-therapeutic antibiotic treatment for pneumonia due to a prescribing error. Five days later he dies of worsening respiratory failure. Overall, this patient was ultimately going to die. Did the sub-therapeutic dosing expedite this? We might ask ourselves, what good would come of telling the family?⁴

Patients, however, have been consistent in their requests for full disclosure in the event of a medical error, and while professional dogma had it that this transparency would increase litigation, the opposite may in fact be true.^7,8 Furthermore, disclosure can be a critical part of the recovery process for both the patient and physician. 

We can feel conflicted in our response to a medical error, caught between how we would like to respond and the respect we have for our patients versus how we think the hospital and legal or professional bodies would want us to respond. This can lead to a cautious and ambiguous response that only serves to aggravate the situation.^8,9

Do: Report, Respond, Review, Recover

While the art of breaking bad news has entered the training curriculum, disclosing error has not. So, what should we do when we realize a mistake has been made?

The SPIKES protocol for breaking bad news may be helpful, with its prompts to consider setting, perceptions, invitation, knowledge, and emotions.¹⁰ Overall, be clear, concise, and timely. To ensure all the necessary information is provided, try to address who was affected, what happened, when and where it happened, as well as why and how it happened. It is okay, and important, to sincerely apologize. Many jurisdictions have “I’m sorry” legislation that protects health care providers from litigation based on an apology.

The recovery process following a medical error is also critical, not just for the patient, but for the physician too. We frequently underestimate the impact of medical error on health care providers, who have been referred to as the “second victim.”¹¹ Numerous emotions can follow a medical error, including guilt, shame, fear, embarrassment, humiliation, loss of confidence, and isolation.

By interviewing physicians involved in medical error, Scott et al. identified a six-stage recovery process: chaos and accident response; intrusive reflections; restoring personal integrity; enduring the inquisition; obtaining emotional first aid; and moving on.¹¹ Outcomes of the last phase, “moving on,” saw physicians either drop out (i.e., change professional role, leave the profession, or move to a different practice location), survive (i.e., continue to perform expected professional role but remain significantly affected by the event), or thrive. Thriving was achieved when something good was made to come of the event.

The study indicates that it is possible to recover from a professional error—however, there is a lack of guidance on how. This was confirmed by a recent systematic review that looked at how physicians respond, cope, and recover from medical error, which demonstrated that while error has a huge impact on physicians mentally, emotionally, and professionally, there is little guidance or help with recovery.¹²

Speaking with a colleague about the event may help to provide support and a different perspective. It is also important to remember and review our successes, which will most certainly be greater than our mistakes, though we tend not to reflect on them enough. Support from family and friends is also important. Finally, professional counselling may be necessary and beneficial.

In conclusion, error is and will be a part of our careers, so we need to accept it and find a way to deal with it. To date, our approach to addressing medical error has focused largely on review of incidents with the aim of future prevention. Although important, this fails to address other critical components in the management of error. Thus, we need a more comprehensive approach that addresses how we report, respond, review and recover from medical error (Table 1).

Dr. McGee is a medical oncologist and breast cancer specialist at the University of Ottawa, Canada, and has served on ASCO's Professional Development Committee. Follow her on Twitter @smcgee_md.

References

1. Kohn LT, Corrigan J, Donaldson MS (eds). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
2. Makary MA, Daniel M. BMJ. 2016;353:i2139.
3. Grober ED, Bohnen JM. Can J Surg. 2005;48:39-44.
4. Surbone A, Rowe M, Gallagher TH. J Clin Oncol. 2007;25:1463-7.
5. Weingart SN, Zhang L, Sweeney M, et al. Lancet Oncol. 2018;19:e191-9.
6. Kaldjian LC, Jones EW, Wu BJ, et al. J Gen Intern Med. 2007;22:988-96.
7. Delbanco T, Bell SK. N Engl J Med. 2007;357:1682-3.
8. Gallagher TH, Waterman AD, Ebers AG, et al. JAMA. 2003;289:1001-7.
9. Gallagher TH, Garbutt JM, Waterman AD, et al. Arch Intern Med. 2006;166:1585-93.
10. Baile WF, Buckman R, Lenzi R, et al. Oncologist. 2000;5:302-11.
11. Scott SD, Hirschinger LE, Cox KR, et al. Qual Saf Health Care. 2009;18:325-30.
12. Sirriyeh R, Lawton R, Gardner P, et al. Qual Saf Health Care. 2010;19:e43.