SAN DIEGO--If a cancer patient dies because of a medical error,
such as an incorrect dosage, it is only human nature to blame
the tragedy on one incompetent person. But finger pointing is
not a useful approach, says George Demetri, MD, since generally
the problem has multiple causes, and a system overhaul may be
Dr. Demetri is associate director in the Office of Medical Affairs
for the newly formed Dana-Farber/Partners Can-cerCare System,
composed of the Dana-Farber Cancer Institute and adult oncology
operations from Mass General and the Brigham & Women's Hospital.
Dr. Demetri spoke at the cancer care conference sponsored by the
Society for Ambulatory Care Professionals and Health Technology
Assessment of the American Hospital Association.
As everyone in the room was aware, Dr. Demetri and his colleagues
learned their lessons the hard way--in the face of a firestorm
of negative publicity after a patient on an experimental protocol
died from chemotherapy overdoses at Dana-Farber. Another patient
suffered severe cardiac failure after receiving the wrong chemotherapy
"There is a clear complexity of treatment errors in most
medical mistakes," he said, whether a wrong leg is amputated
or an incorrect drug dose given. "One single individual acting
alone cannot, in general, cause these errors," he said.
Citing liberally from the pioneering work on medical errors from
Dr. Lucian Leape, Harvard School of Public Health, Dr. Demetri
said that most treatment errors represent simultaneous failures
of multiple and interacting clinical systems.
"I think there are great lessons to be learned in studying
how the systems failed, where the safety overlaps were insufficient
to prevent the error, and how to improve our clinical fail-safe
systems," he said.