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 in order.
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 doses.
"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.