Clinical Oncology and Error Reduction E-Book

Antonella Surbone

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 406

Veröffentlichungsjahr: 2015

Beschreibung

Clinical Oncology and Error Reduction fills a gap - the lack of a single volume on medical error in the vast field of cancer care - that has existed since a 1999 Institute of Medicine's report introduced the term 'medical error' as a topic for doctors and patients alike. The volume, edited by Antonella Surbone, M.D., a clinical oncologist and Michael Rowe, Ph.D., a medical sociologist, includes chapters written by experts on the topic including physicians, nurses, patients, and advocates, and covers a wide range of topics essential to an understanding of the unique character, challenges, and needed responses to the risk, incidence, and aftermath of medical error in the diagnosis, treatment, and aftermath of treatment for cancer. Clinical Oncology and Error Reduction will serve as the standard for framing the discussion of error in the field for oncologists, epidemiologists, nurses, healthcare administrators, researchers, and scholars. An indispensable handbook for all clinical oncologists, their staff, nurses, and oncology residents and fellows, this book: * Contains practical information for immediate clinical application * Covers topics such as patient safety, error prevention, quality improvement, errors disclosure and apology, and the impact of errors on patients and doctors * Each chapter contains special "take home" points that highlight issues of particular clinical relevance and application * Prepared by an expert, multidisciplinary, international team of physicians, nurses, researchers, hospital administrators, bioethicists, patients and patient advocates Dr. Surbone shared with ASCO Connection her insights about patient safety and medical errors and offered a glimpse into the history that led to this new book: https://connection.asco.org/magazine/features/opening-dialogue-about-medical-errors

Leseprobe

Table of Contents

Cover

Title Page

Copyright

Dedication

List of contributors

Foreword

Preface

Acknowledgments

Chapter 1: Introduction to oncology and medical errors

Outline of the book

Medical error, oncology patients and their family members

Cultural attitudes and practices regarding disclosure

Medical error, oncology, and the law

Ethical implications of medical errors in oncology: responsibility and accountability

Conclusion: humanity and humility in facing medical errors in oncology

References

Part I: Medical errors and oncology: background and context

Chapter 2: Recognizing and facing medical errors: the perspective of a physician who is also the patient

Failure to diagnose the cancer recurrence

Failure to remove the recurrent tumor using laser

Failure of nurses to respond to breathing difficulties in the Surgical Intensive Care Unit

Failure to respond to breathing difficulties in the otolaryngology ward

Premature oral feeding after laryngectomy

Nursing mistakes

Conclusions

References

Chapter 3: Psychological and existential consequences of medical error for oncology professionals

Connection

Attachment and aversion

Vulnerability and wholeheartedness

Shame

I wish I'd thought of that …

Humility and admiration

Respect

Emotional intelligence (EI)

Resilience

Social networks

Burnout syndrome

Compassion fatigue

Moral distress

Transparency and professionalism

Religion and spirituality

Checklists: rites and rituals

Self-care

Mindfulness

Mozart effect

Thankfulness and wisdom: humanities

Supporting oncology professionals after a medical error

Conclusion

References

Chapter 4: To sue or not to sue: restoring trust in patient–doctor–family relationships

Introduction

Study: why people do not sue

First authors' experience

Second author comments

Conclusion

References

Part II: Improving patient safety in clinical oncology practice

Chapter 5: Prevention of errors and patient safety: oncology nurses' perspectives

Introduction

Patient misidentification

Chemotherapy errors

Wrong drug errors

Dosing errors

Calculation errors

Scheduling errors

Wrong route of administration

Summary

Strategies to prevent medical errors in oncology

Strategies to prevent patient misidentification

Prevention of chemotherapy errors

The patient's role in error reduction

Summary

References

Chapter 6: Prevention of errors and patient safety from the oncologist's perspective

Chemotherapy safety

Quality assessment tools

Radiation oncology and surgical oncology

Recommendations for safer oncologic care

References

Chapter 7: Disclosing harmful medical errors

Why this is important?

Why doctors don't disclose errors

What do patients want when medical errors occur?

Training in error disclosure

References

Chapter 8: Do cross-cultural differences influence the occurrence and disclosure of medical errors in oncology?

Introduction and background

Errors, language, and culture

Cross-cultural communication and bias

Error disclosure

Five strategies to reduce errors

Conclusion

References

Part III: Cancer patients, oncology professionals, and institutions against medical errors

Chapter 9: Prevention of errors and patient safety: institutional perspectives

The changing context of healthcare institutions and patient safety

Institutional core competencies for safety

The future of safety in healthcare and cancer care institutions

References

Chapter 10: Professional and ethical responsibilities in adverse events and medical errors: discussions when things go wrong

Introduction

Why should we disclose? Ethical, practical, and evidence-based support for disclosure of adverse events

What we do at present

Communicating adverse events in oncology

Building a culture of disclosure

Conclusion

References

Chapter 11: Medical error and patient advocacy

Introduction

Medical error

The patient safety movement

Beyond medical error and patient safety: patient advocacy

References

Chapter 12: Conclusion: the “given” and “therefores” of clinical oncology and medical errors

The nature of oncology care and patient and oncologist experience in regard to errors

Disclosure

Education, training, and research

References

Index

End User License Agreement

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Guide

Cover

Table of Contents

Foreword

Preface

Part I: Medical errors and oncology: background and context

Begin Reading

List of Illustrations

Figure 3.1

Figure 3.2

Figure 3.3

Figure 6.1

Figure 6.2

Figure 10.1

List of Tables

Table 1.1

Table 2.1

Table 2.2

Table 5.1

Table 5.2

Table 6.1

Table 7.1

Table 7.2

Table 7.3

Table 10.1

Clinical oncology and error reduction

Antonella Surbone MD, PhD

Department of MedicineNew York UniversityNew YorkUSA

Michael Rowe PhD

Department of PsychiatryYale School of MedicineNew HavenUSA

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Library of Congress Cataloging-in-Publication Data

Clinical oncology and error reduction / [edited by] Antonella Surbone, Michael Rowe.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-118-74906-7 (cloth)

I. Surbone, Antonella, editor. II. Rowe, Michael, 1947-, editor.

[DNLM: 1. Medical Errors— prevention & control. 2. Medical Oncology. 3. Patient Advocacy. 4. Patient Safety. 5. Physician's Role. QZ 200]

RC263

616.99′4— dc23

2014032060

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

To Katherine Russell Rich, Jesse Harlan-Rowe, and our families

List of contributors

Walter F. Baile MD

Departments of Psychiatry, Behavioral Science and Faculty and Academic Development, The University of Texas MD Anderson Cancer Center, Houston, USA

Joseph R. Betancourt MD, MPH

Director, The Disparities Solutions Center, Massachusetts General Hospital, Boston, USA

Nie Bohlen RN, MSN

Division of Hematology/Oncology, Massachusetts General Hospital, Boston, USA

Itzhak Brook MD, MSc

Department of Pediatrics, Georgetown University School of Medicine, Washington, USA

Mary J. Chalino

Division of Hematology Oncology, Massachusetts General Hospital, Boston, USA

Juanne N. Clarke PhD

Department of Sociology, Wilfrid Laurier University, Waterloo, Canada

Bradley L. Collins

Division of Hematology Oncology, Massachusetts General Hospital, Boston, USA

Daniel Epner MD

Department of Palliative Care and Rehabilitation Medicine, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA

Patrick Forde, MD

Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA

Alexander R. Green MD, MPH

The Disparities Solutions Center, Massachusetts General Hospital, Boston, USA

Inga T. Lennes MD, MPH, MBA

Director of Clinical Quality, Division of Hematology/Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, USA

Eric Manheimer MD, FACP

Department of Medicine, New York University School of Medicine, New York City, USA

Richard T. Penson MD, MRCP

Division of Hematology Oncology, Massachusetts General Hospital, Boston, USA

Martha Polovich PhD, RN, AOCN

B.F. Lewis School of Nursing & Health Professions, Georgia State University, Atlanta, USA

Michael Rowe Ph.D., M.P.A.

Yale School of Medicine, Department of Psychiatry New Haven, CT, USA

Lidia Schapira MD

Division of Hematology and Oncology, Massachusetts General Hospital, Boston, USA

Meghan E. C. Shea MD

Division of Hematology/Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, USA

Antonella Surbone MD, PhD, FACP

Department of Medicine, New York University Medical School, New York, NY, USA

Evelyn Y.T. Wong

Division of Hematology Oncology, Massachusetts General Hospital, Boston, USA

Albert W. Wu MD, MPH

Center for Health Services and Outcome Research, Johns Hopkins Bloomberg School of Health, Baltimore, USA

Foreword

In reading this well organized assembly of essays – in particular its Introduction, Preface, various chapters, and the Conclusion – two things stand out: courage and the need for narrative in medical education. There is no question that this book is an exercise in courage; for the risk its contributors, mostly oncologists, and its editors take in acknowledging errors in clinical oncology opens a truth that some may find best left unsaid. However, its confluence of narratives does so in order to point its collaborators and readers toward ways to reduce errors in clinical oncology. Indeed, as the editors recognize, clinical oncology

renders the discipline and practice of oncology both vulnerable to the difficulties associated with identifying, understanding, disclosing, and managing medical error and its aftermath and uniquely situated to provide medical leadership regarding medical error within and beyond its disciplinary boundaries to medicine.

This collection represents the initiation of a needed conversation about medical error in oncology and a salutary invitation to the wider community of professional clinical oncology – its physicians, physician – scientists, specialized nurses, and others, notably cancer patients such as myself – to listen to this conversation and perhaps enter into its continuation. It is a mindful and responsible call to arms, and it will reward the reader who hears and understands the personal and existential as well as the clinical dimensions of its various narratives. In response to the generous invitation from the editors, Drs. Surbone and Rowe, I offer the following Foreword as a patient's perspective for the reader and also to call upon you to enter this important conversation.

According to the early modern philosopher, Baruch Spinoza, presentation of fear originates from a natural fear of death. So the fear of physical pain or emotional pain is an expression of the fear of death. For the most part palliative medicine is close to alleviating physical pain adequately, but it is far from close enough to addressing the existential pain at the core of emotional suffering. Indeed, this is the case because the latter belongs to a “form of life” which crosses a divide between physical and emotional pain. The existential pain that arises in the doctor – patient relationship may be more or less bearable. Too often when it is less bearable for the patient due to a clinical error she or he, or the family, turn to legal action. The resultant adversarial relationship also falls short of addressing adequately the existential, emotional pain because it belongs to a different “form of life” and exacerbates the harm of the disease. Consequently, when medical errors occur and harm is done, there is emotional suffering for both the patient and the doctor which complicates and inhibits the art of clinical medicine. Most important, the resultant harm obstructs getting closer to the truth of the error and restoring the needed balance and trust in the subsequently altered doctor – patient relationship.

Our – that of both doctors and patients – need to console ourselves from the outset of the dis-ease, especially in the case of cancer, is often expressed as an assurance that the oncologists armed with modern, science based medicine are in control of the patient's dis-ease. But such “control” rarely, if ever, happens, and the needed trust in the doctor – patient relationship can hide from us our vulnerability to accident or even malice, and no legal instrument can restore the needed trust. The truth is that the trust required by both cancer patients and clinical oncologists, lies with a presupposition of control over the invisible lives of our own insurgent, rebellious cells that give clinical oncology its life and meaning. But if Karl Popper is right, and I believe he is, and even our best scientific theories are fallible and therefore provisional, then the control on which science-based medicine is predicated seems haunted by a myth of control of the invisible “malady of all maladies.”

The practice of clinical oncology may be done more or less well, and excellence in it is achieved not by memorizing formulae or consulting algorithms for diagnosis, prognosis, and prescriptions for therapy. IBM's Watson may assist the well-informed clinician but it cannot substitute for the clinical art. Excellence in clinical practice is achieved not by formulae alone, but by developing a highly nuanced sense of what is more fitting in the particularities of a presenting clinical situation. This nuanced sense within the practice of a craft/art is a knowing how, a practical judgment within and on the particularities of the concrete situation. It is what Aristotle called phronesis, a deliberation and judgment of what action to take – whether in legal matters, or in moral matters, or in political matters or in medical matters. It is a medical phronesis learned by a kind of imitation of those who have learned from experience how to practice their craft or art well. Learning it begins in the clinical curriculum of medical schools, and continues in the apprenticeship of post medical school residency. However, it must continue beyond residency and renew itself in the experience as the art of the judgment is executed and incorporated within the individual toward her perfection as a clinician. This art must learn, from both its successes and its failures, how to correct its errors. As such it calls for what might be the habits of good practice, the virtues of a good clinician as a clinician. At the least these include courage, truthfulness, confidence balanced by truthfulness to counter the temptation to hubris in so powerful a knowledge, and a kind of Socratic wisdom about the practice that calls forth a perfecting of the art of medicine.

This learning how to learn from one's errors in practice has very real consequences which call for a courage, first to face your own theoretical fallibility and existential vulnerability, and to acknowledge it in the clinical situation to yourself, your peer oncologists, and to your patients if an error is made and to learn from that error. It is not the fallibility of an uneducated ignorance, but rather that of a well-established science-supported practice. Indeed, inasmuch as both the science and the practice are fallible, it proceeds with an attitude of truthfulness which is ever mindful that there is always more to be learned. Consequently, this attitude proceeds as an educated ignorance that generates the confidence that acknowledges what experience teaches and fails to teach, the perspicacity to sense the difference, and a humility to learn from this difference what had worked in clinical practice but no longer will without reform. The needed reforms are reforms of standards of practice as heuristic guides which may or may not need to await the reform of the best theories underlying the clinical practices. As heuristic the standards are not universal, abstract rules but guidelines embedded in the practices of good clinicians whose own clinical phronesis enables them to recognize tacitly the heuristic guidelines in the medical practices of their best colleagues. Nonetheless, identifying and imitating the best practices of individual oncologists is not enough, for as some contributors to this volume recognize, the best medical phronesis that reduces medical errors needs to enter the medical leadership at institutional and systemic levels if an internalization of the individual clinical virtues is to become a virtue characteristic of the clinical medical community as a whole. It's a daunting challenge to reduce medical errors and the existential pain it brings to both patient and doctor; but well worth the needed effort as the following narratives by concerned oncologist and associated scholars make clear.

Dominic J. BalestraProfessor of Philosophy, Fordham University and cancer patientFormer Dean of Arts and Science FacultyFormer Chair of the Department of Philosophy

Preface

It has been said that if you scratch the surface of a person's work you will find a personal concern or experience, a passion – for knowledge, justice, solution to a burning problem, or other – that prompts or helps to drive her or his work, even when that work is highly rational, scientific, and impersonal on the face of it. The reach of that rule of thumb is not clear, but there is some truth in it for us, the editors of this volume.

Antonella Surbone, a medical oncologist who trained and worked in Italy and in the USA, gathered clinical experience on the importance of patient safety and communication with cancer patients. From my almost 20 years of oncology practice in New York at Memorial Sloan Kettering Cancer Center first and Bellevue Hospital, I came to understand the urgent need to apply the new culture of prevention and disclosure of medical errors indicated by the 1995 IOM Report “To Err is Human” to the field of oncology. Complex and multidisciplinary treatments are required – at times of an experimental nature – in oncology, and almost all cancer patients interact with different specialists during the course of their illness, making the art of oncology prone to the occurrence of medical errors. In light of my personal and scholarly interest in the ethical and social implications of medical oncology and in cross-cultural differences in its practice worldwide, I focused my attention and research on the impact of medical errors on the patient–doctor relationship and the reciprocal trust that sustains it. Observing and experiencing on a daily basis the strong bonds that can develop between cancer patients and oncologists and nurses, and witnessing and studying the contextual and cultural dimensions of clinical cancer care, I also explored ethical and communication aspects of medical errors in oncology.

During roughly the same period of time, the second editor, Michael Rowe, a medical sociologist, was studying the encounters, negotiations, and transactions of persons who were homeless with mental illnesses and outreach workers, along with the social, institutional, and professional contexts that shaped those encounters. During this time my son underwent organ transplant surgery and died from complications of the surgery after a three-month hospitalization. I wrote about Jesse's experience of medical error and other aspects of illness and patient–doctor relationships from both personal and professional perspectives in a book and in medical, narrative medicine, and bioethics. As examples, I wrote that closure after the death of a loved one is a myth, and that breaking the barrier of silence that still surrounds most medical errors could ease the suffering and anguish of patients and families and of health professionals.

Antonella, as Ethics Editor of Critical Reviews in Oncology/Hematology, became aware of Michael's work and asked him to write an article on the theme of doctor's responses to medical errors, with an emphasis on doctors' and strong emotions of participation in a medical error and doctors' anguish over harm done to patients, how to talk to patients about errors, and how they lived with them personally and professionally. She wrote a commentary that was published with the article, noting and expanding upon its themes and suggesting topics for future exploration. Our shared interest in medical error, patient–doctor relationships and communication, and their social and cultural contexts subsequently led us to conduct two educational sessions at the American Society of Clinical Oncology Annual Meetings of 2005 and 2012, to joint writing and research, and to this volume.

Some readers, especially those acquainted with the vast research, policy, and scholarly literature on medical error and patient safety, will notice that a few important areas such as litigation and others are not the core topics of our book. While each of these domains is addressed in part in different chapters, often through illustrations, our backgrounds and particular medical and humanistic concerns are reflected in the main themes and underpinnings of this book, the first volume to our knowledge on the topic of medical errors and error reduction in clinical oncology.

The nature of oncology care renders the discipline and practice of oncology both uniquely vulnerable to the difficulties associated with identifying, understanding, disclosing, and managing medical error and its aftermath, and uniquely situated to provide medical leadership regarding medical error within and beyond its disciplinary boundaries to medicine. We hope that our book will start a conversation both on confronting medical error in oncology and in taking up the unique contribution that the field of oncology and oncology professionals can make to addressing medical error and its consequences, focusing on restoring trust among all partners involved.

Acknowledgments

We thank all contributors, our patients and their family, our colleagues and teachers, and our families for their constant support.

Antonella Surbone & Michael RoweNew York & New Haven

Chapter 1Introduction to oncology and medical errors

Antonella Surbone1 and Michael Rowe2

1Department of Medicine, New York University, New York, USA

2Department of Psychiatry, Yale School of Medicine, New Haven, USA

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. [1] 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. [2]

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. [3–5]

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.

Our aim in this book is to discuss key aspects of medical errors in clinical oncology and provide recommendations for improvement in patient safety and reduction of medical errors. We also consider the impact of a medical error and lack of its aftermath – including proper or insufficient disclosure or its absence and lack of a heartfelt apology on patient–doctor relationships and trust. Table 1.1 below suggests key areas of attention in responding to medical error beyond clinical interventions to correct for their overall impact on cancer patients and their families.

Table 1.1 Responding to medical errors in oncology: areas for study and action.

Study of the epidemiology of errors in oncology

Analysis of specific causes of errors in oncology

Institutional disclosure policies and process incorporating a psychological understanding of the experience of error and attention to the lived experience of error for patients, family members, oncologists, and nurses

Clear ethical and professional standards for basic content of disclosure that respond to the tendency to hedge or redefine disclosure

Training in error disclosure, incorporating an understanding and response to the psychological and emotional aspects of disclosure for patients and family members

Training on the ethics of individual accountability even when errors stem from team or system failure

Education on the redemptive value of apology and forgiveness

Emotional support following errors for all parties

Building bridges among patients, family members, and oncology professionals after disclosure to restore trust in the patient–doctor relationship, institutions, and medicine

In this book, we address key aspects of medical errors in oncology, a field in which treatments are complex and patients are exposed to multiple potential sources of adverse events and errors, from diagnosis to active therapy to long-term survivorship, or palliative care and end-of-life stages. Cancer patients may be enrolled in clinical trials or receive relatively new drugs for which the knowledge of what constitutes an adverse event is lacking or preliminary, and in which a clear distinction between adverse events and medical errors can be, likewise, difficult to make. The use of detailed therapeutic protocols reduces the risk of harmful errors, yet the need for multiple concomitant medications or treatments may increase their occurrence. Similarly, the involvement of interdisciplinary teams in the care of cancer patients may increase the possibility of errors while, at the same time, contributing to the capacity to prevent or detect them early on due to multiple opportunities to intercept a mistake. Increasing use of electronic records and orders is believed to contribute to limit the risk of medical errors in clinical oncology, but this technology is not available or feasible for use in all countries or local contexts.

In addition to discussing error prevention and correction at individual, institutional, and system levels, we consider the impact of errors on cancer patients, their family members, and oncology professionals, and emphasize proper and empathic communication as a means of restoring trust in the patient–doctor relationship after an error has occurred. We also identify gaps and barriers to further progress in these areas. We first briefly review the contents of the individual sections and chapters in this volume below. We then add a few considerations of themes that, for lack of space, have not been systematically addressed in individual chapters, or that we explore from different standpoints: medical error, oncology patients and their family members; cultural attitudes and practices regarding disclosure; the impact of medical errors on oncologists; and medical errors, oncology, and the law. We also explore the ethical value of taking individual responsibility and accountability for medical errors, even while shifting from a culture of moral and legal blame to the more effective one of a system approach to patient safety.

Outline of the book

The first of three sections in this volume concerns the background and context of medical errors in oncology. Itzhak Brook, a physician writing as a cancer patient and survivor, describes in chilling detail the multiple medical and surgical errors he experienced in his treatment for hypopharyngeal squamous cell carcinoma, a serious form of throat cancer. Dr. Brook also offers practical recommendations for preventing errors in hospitals and medical offices and enhancing competent disclosure of errors to patients, while supporting healthcare professionals in doing so. He argues for the active collaboration of patients and families with oncologists and nurses in preventing medical errors or limiting their damage. He also refers with respect and gratitude to the many staff members who cared for him even in the context of multiple errors.

Drs. Mary Chalino, Evelyn Wong, Bradley Collins, and Richard Penson explore in depth the psychological and existential impact of medical error on oncology professionals, including guilt and shame that, if unaddressed, can lead to burnout, compassion fatigue, and other negative consequences. The authors examine various models of personal coping with involvement in medical error, including spiritual and religious resources and mindfulness meditation in the context of individual resilience and the larger contexts of religion and spirituality, wisdom literature, and the humanities. Little attention has been paid in the research and scholarly literature to these aspects of how oncology professionals cope with the aftermath of medical errors – a void that this chapter contributes to filling.

Rounding out this first section, Drs. Michael Rowe and Antonella Surbone, editors of this volume, take a turn as chapter authors. We chose to contribute to our book with a report, based on in-depth interviews with patients and physicians facing a variety of medical scenarios, on why people who believe they or their loved one experienced a harmful medical error do not pursue malpractice litigation. We also add our own personal family and professional reflections to this research, including the relationship of errors to the erosion, and possible rebuilding, of trust in relationships between cancer patients and their oncologists and nurses.

The second section of this volume focuses on patient safety in clinical oncology practice. Dr. Martha Polovich gives the reader a bird's-eye, case-example rich, and scholarly perspective of the role of oncology nurses in preventing medical errors. Dr. Polovich's account emphasizes the complexity, and thus the ample room for error and lapses, of patient safety efforts in oncology care, and the integral involvement of nurses in these effort. She discusses efforts to address potential threats to patient safety including recommendations for developing and implementing clearer procedures, the use of new medical technology to assist in reducing medical errors, and individual and collective practice in the context of a medical culture of patient safety.

Drs. Walter Baile and Daniel Epner offer a broad ranging review on disclosure of harmful medical errors. They review the histories of silence, individual blame, the lack of or misleading disclosure of harmful error to patients and family members, and a shift in medical culture toward correcting such deficient responses. They offer specific examples of “how” and “how not to” disclose, including disclosure statements and procedures. At stake in getting communication of medical errors right with patients and their families, the authors argue, are improvements in patient safety and the health of patient–doctor relationships.

Dr. Lidia Schapira, Joseph Betancourt, and Alex Green take up the impact of cross-cultural differences between caregivers and their patients and patient family members on patient safety, a critical topic in medicine and in the context of increasingly diverse societies worldwide. Using data and examples from the United States, the authors point out potential barriers to patient safety in cross-cultural care, including different cultural values and language and the challenges posed by low literacy among patients and family members belonging to the non-dominant culture of the country in which they are treated. Addressing these concerns, they argue, requires increased knowledge and training for oncology professionals, the use of skilled interpreters, and institutional commitment to improving cross-cultural care in general and in relation to cancer patient safety.

In the third and final section of this volume we examine at the intersection of patient, professional, and institutional needs and realities with regard to patient safety and reduced medical error in oncology care. Dr. Eric Manheimer, writing of ever-larger and more complex medical institutions, discusses their historical and recent roles in causing medical error and undermining public safety. He places the tension between past failures and recent efforts to reform medical institutions in the immediate context of the Affordable Care Act in the United States. The applied theory of High Reliability Organization emerges, in his view, as the most promising model of future health care for the USA. Dr. Manheimer draws on his expertise as a medical director of large hospitals in which many cancer patients are treated and on his experience as a cancer survivor who has written about his own illness and recovery.

Drs. Patrick Forde and Albert Wu address the oncologist's professional and ethical responsibilities with respect to disclosure of adverse events and medical errors. Their chapter complements, in part, Drs. Baile and Epner's discussion of communication about medical errors. Here, the authors focus on ethical arguments for disclosure, such as the loss of autonomy and justice for patients who are not informed of adverse event and the potential for future or continued errors in cases where errors are not disclosed. They review the evidence for and against full disclosure, and the relevance of it and related issues to the special needs of cancer patients. They also present detailed case discussions to illustrate the fact that good communication between oncology professionals and cancer patients is dependent, and also can build, upon previously achieved mutual trust before a medical error occurs.

Dr. Juanne Clarke closes out this section with a reminder from a sociological perspective that the dominant forms of viewing and discussing medical error stem from a medical definition of error that is “not clear, objective, or self-evident.” The definition and resulting efforts to address medical error and patient safety, she argues, are fueled by a perspective and a theory of error that are insufficiently aired and debated, given the medical perspective's dominant position, voice, and resources. Dr. Clarke considers the broader patient definition of error and the need for stronger patient-based and -oriented advocacy to enhance cancer patient safety.

In a concluding chapter, we briefly review the conceptual and practical implications of the contributions of our authors. We also suggest possible future directions for practice and research that may contribute to reducing medical errors and enhancing patient safety in oncology.

Medical error, oncology patients and their family members

Patients often have a broader understanding and definition of medical errors than physicians or researchers. They may, for example, include among medical errors the physician's failure to communicate effectively with them after the medical error has occurred. Individual physicians' or institutional arrogance, while not a constitutive element of the medical definition of error, has been described by many patients as contributing to their perception of medical errors and to the difficulty of repairing a breach in trust.

Patients and family members also may live with the physical and emotional consequences of the error for years, and lack of physician empathy and honesty in the aftermath of error can exacerbate their suffering. Yet most of the literature on medical error focuses on a narrower set of responses and time, including whether or not, and when, to pursue or forego a malpractice lawsuit. Education of all parties about the psychological–emotional consequences of adverse events and medical errors, and creation of new standards of practice in response to this extra-clinical domain of error, are needed. In addition, “near misses” that may be caused by excessive patient caseloads are also a cause of shame and fear for physicians, and are rarely addressed in terms of their emotional impact on doctors. [6]

Oncology patients, like others with serious or acute illnesses, are vulnerable due not only to their illness but also to the inherent power asymmetry between patients and oncologists. [7] Patients place their trust and lives in the expertise and person of their oncologists. From this perspective, disclosure is not only the right thing to do but follows directly from the fiduciary nature of the therapeutic relationship in clinical medicine. The practice of oncology, however, with its use of detailed protocols, multiple experimental medications, and interdisciplinary teams, along with the toxicity of the medications it offers, presents difficulties, at times, with regard to assessing whether an adverse event is a side-effect of treatment or the result of medical error. [8] These quandaries, in turn, can tempt oncologists to rationalize away some errors and question the need to disclose them to patients. [9, 10] On the other hand, oncologists may be so acutely aware of the depth of suffering of their patients that they refrain from disclosing errors, or offer only partial disclosure – especially when the error caused no permanent harm – in order to shield patients and their families from additional suffering and anguish. [9]

Cultural attitudes and practices regarding disclosure

Attitudes and practices of truth telling to cancer patients vary widely by culture and countries. Despite a sharp trend toward disclosure of diagnosis and prognosis worldwide based on respect for patient autonomy even in cultures oriented more to family and community values than individual rights, partial disclosure is still the rule in many non Western countries. [11] It is difficult to disseminate and implement recommendations for error disclosure in cultures where cancer patients may be unaware, or only vaguely aware, of their illness status and prognosis.

In Anglo-American countries, with their traditions of providing extensive information to patients, a disclosure statement may be truthful yet not appropriate in a given context. In addition, examination of the nuances of truth telling in patient–oncologist relationships teaches the physician that statements of fact and truth telling are not synonymous. Oncologists may hide behind delivering a torrent of medical information that, while factually correct, may confuse patients rather than help them face the truth of their illness. [11]

Oncologists, more than most other physicians, must often communicate devastating news to their patients. The manner and content of the communication process can spell the difference between mere fact giving and truth telling. An oncologist may tell his patient that she has an aggressive form of cancer and has only months to live, or may essentially deliver this same message in the context of assuring her that he is committed to caring for her until the end and to offering all appropriate options, from antineoplastic treatments to palliative and end-of-life care. [12] The first statement voices the “plain truth” more forcefully than the second; the second provides an opening for dialog, giving the patient an opportunity and time to absorb the factual medical truth and prepare herself to face it together with her oncologist and her loved ones.

Perhaps the most striking gap in ethical approaches to medical errors and disclosure involves the “street-level” context of the ethics of medical care, in which competing interests and constituencies make collective and continuous decisions over time and interventions respond to earlier interventions, setting the stage for new ones. This model of decision making contrasts with that of the doctor who makes medical and ethical decisions on her own and in relation to generalized normative standards, but mostly in reference to the particular situation and patient in front of her. [13] Another gap in the ethical approach to disclosure involves the need to help patients, family members, and doctors come to terms with the impact of medical errors over time. Such an approach would involve addressing not only the lack of consensus among doctors, institutions, patients, and family members about what should be disclosed in the aftermath of adverse events, but what medicine's roles and responsibilities are regarding the long-term impact of harmful error for patients and family members as well as for oncology professionals.

Regarding disclosure of medical errors, telling the truth to patients and their families and apologizing to them involves both ethical and psychological–emotional elements for physicians, in addition to legal and professional concerns. For patients and family members, the visceral experience of error and judgment of physicians' and medical institutions' violation of medical and ethical standards may be intermixed with the psychological–emotional elements of shock, grief, loss, survivor guilt, and sense of isolation. Other factors may include stigma associated with physical effects stemming from the medical error and a change in the patient's potential role in the family due to reduced ability to work or carry out other functions. In addition to the implications of being sued, which range from financial losses to professional reputation, physicians also suffer from subjective responses to medical errors that they have committed or witnessed. [14] A lingering belief in physician infallibility contributes to a culture of doctors' silence about error. Yet accompanying the message of infallibility are physicians' knowledge that errors do occur and the anguish they experience when the error is their own.

Studies and narrative accounts have examined the experience of medical error for physicians, including oncologists, who experience considerable distress in the aftermath of committing or witnessing medical errors. [14, 15] Errors negatively affect oncology professionals' self-confidence and afflict them with feelings of guilt, of being found out, and of fear of colleagues' ridicule. Such negative reactions, combined with fears of malpractice lawsuits and buttressed by traditional messages of silence from their institutions, leave doctors and nurses with few places to go to discuss and try to work through their feelings. Mortality and morbidity conferences or similar discussions of medical errors among team members focus on medical and surgical aspects of errors, and rarely are an appropriate setting for doctors to express their emotional response to errors and their need for support.

Oncologists, like physicians in other specialties who work with very ill patients over long periods, are especially prone to burnout. [16, 17] In oncology, the patient–doctor relationship occurs in the context of uncertainty over the course of the disease, the prospects for treatment effectiveness, and patients' physical and existential suffering. Uncertainty and existential suffering are common to oncologists as well. [18] For oncologists, the close relationships they develop with many of their patients may make error more difficult for them to bear and to confess to patients. At the same time, as noted above, severe illness and imminent mortality among their patients may tempt oncologists to withhold information on error or adverse events. [9] This temptation may persist even in the face of evidence that disclosure of error can reduce its psychological impact and that failure to disclose can heighten feelings of distress following errors and negatively affect oncologists' relationships with current and future patients. Thus, counseling oncologists and nurses regarding medical error and its aftermath should be a priority and dedicated psychological services should be made available to them.

Medical error, oncology, and the law

The legal–malpractice aspects of medical error have received much attention in the medical, ethical, and legal literature. [19] They appear to be perhaps less pressing in oncology than in many other medical disciplines and specialties. In the 2013 Medscape Malpractice Report, for example, the oncologist's risk of a malpractice lawsuit, at 4%, ranks well below internal medicine, family medicine, obstetrics–gynecology, psychiatry, and cardiology, [20] with comparatively low malpractice premiums for oncologists as a result. [21] The Medscape finding may partly reflect the often-expected poor outcome of care in the context of aggressive forms of cancer in many patients. Still, based on these data, one in twenty-five oncologists can expect to be sued at some point in their careers. In addition, the Medscape report does not, nor does it claim to, take into account the potential damage to patient–doctor relationships in the care of the unknown numbers of cancer patients and family members who experienced dissatisfaction with their care, feel that errors or substandard care occurred, and/or may have considered or explored the possibility of a lawsuit.

Dr. Patricia Legant has written of the key risk areas for litigation in oncology care, among them delays in diagnosis, errors in chemotherapy dosing, pain control, and lack of, or poorly communicated, informed consent for surgical procedures. [21] Delays in diagnosis are most often laid at the door of primary care physicians, pathologists, and radiologists rather than oncologists, although oncologists are vulnerable to diagnosis-based lawsuits for missed or late diagnosis of late relapses or secondary tumors in cancer survivors. Regarding chemotherapy dosing errors, Dr. Legant notes a change in oncology care that increases the risk of error:

Until recently, oncologists would write and then communicate orders to office-based pharmacists and nurses, who would subsequently prepare and administer the drugs under their direct supervision. With recent changes in insurance reimbursement, however, drug preparation and administration are moving outside the office and into hospital outpatient departments. [21] Order transfers in general involve a risk of error, and this risk increases in the case of this relatively new scenario given the inexperience of hospital staff versus oncology office staff in handling orders.