2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

PREVENTING MEDICAL ERRORS
more difficult because insertion of an endoscope and visualization
of the area were more difficult.
I learned the hard way that experience is of primary
importance with this kind of surgery. Since the frequency of
throat cancer has declined in the United States, there are
fewer patients with this cancer and surgeons have less
experience removing it. With fewer patients, the expertise in
its removal and care is concentrated in fewer institutions.
Even though my surgeons had very little experience using
laser to remove my type of cancer, they still offered to
remove it using this technique. One of my surgeons summarized
his philosophy about learning new procedures as: “See
one, do one, teach one.” I believe the best approach should
be: “See a hundred, do 200, teach one.”
Although the error made by my surgeons was very regrettable,
they admitted their responsibility for making it. This
made it easier for me to accept the error and allow them to
try to remove the cancer again, even though they suggested
that I could seek care in another center.
Failure of the Surgical Intensive Care Unit Staff to
Respond to Breathing Difficulties
I had experienced multiple unsafe situations because of
errors made by nurses. A serious situation occurred one day
after my laryngectomy while I was still in the Surgical
Intensive Care Unit (SICU). I suddenly felt an obstruction of
my airway and reached for the call button. I could not find it
because it had fallen to the floor. The nurse who cared for me
also cared for two more patients and was absent when I
needed her help. I was unable to move because I was
connected to multiple tubes and lines. I attempted to get the
attention of the staff by disconnecting my heart- and oxygensaturation
monitors, and even though I was a few feet away
from the nursing station, I was ignored until my wife arrived
about 10 minutes later and called for help. I was helpless in
getting assistance without a voice and was desperately in
need of air while medical personnel passed me by.
When my wife complained about what happened to the
nursing supervisor and SICU attending physician, she was
rudely rebuffed. When I informed my surgeon about the
incident, he just shrugged his shoulders and told me that he
had little influence on what happens in the SICU, but he
assured me that things would be much better for me when I
was moved to the otolaryngology floor. The lack of willingness
of my surgeon to act upon my complaint was very
disappointing. Instead of addressing the problem in the
SICU that cares for his patients when they are critically ill,
KEY POINTS:
● Medical, surgical, and nursing errors are common in
patient care.
● Some medical errors may be life threatening and can
lead to increased morbidity and mortality.
● Preventing such errors is of utmost importance.
● A dedicated patient advocate, such as a family member
or a friend, is very much needed for all hospitalized
patients.
● Open discussion of such errors may decrease them
and eventually lead to better care.
he comforted me by promising better care when I will be less
needy for it.
Failure to Respond to Breathing Difficulties in the
Otolaryngology Ward
A similar incident also occurred in the otolaryngology
ward a week later when a nurse failed to respond to my
urgent call to suction my trachea. It happened after I
suddenly experienced difficulty in breathing because mucus
was blocking my airway. Even though I pressed the call
button, no one came to my assistance. I was finally able to
get the attention of a nurse assistant who informed me that
my nurse was on a break. The nurse assistant was not
trained in suctioning airways, but she promised to look for a
nurse. It took my nurse 15 minutes to come to suction my
trachea. I later learned that she was busy ordering supplies
on the phone during that time.
I was very distressed as I was struggling to breathe in.
Present in the otolaryngology ward during this time were
two resident physicians and several nurse assistants, yet no
one came to my help. It is clear that even on a ward
dedicated to helping people with breathing difficulties, there
were distractions that prevented physicians and nurses
from paying attention to their patient’s urgent needs.
Even though I brought the incident to the attention of the
nurse supervisor and the head surgeon, I never received any
feedback from them about what was to be done to prevent
such incidents in the future. The lack of response was
inappropriate and contributed to my frustration and anxiety.
Prematurely Feeding by Mouth
One of the most serious errors in my care was feeding me
by mouth with food a week too early. Early mouth-feeding
following laryngectomy with free-flap reconstruction can
lead to its failure to integrate. The oral feeding continued for
over 16 hours. The premature feeding was stopped only
because I continued questioning this practice and brought it
to the attention of the attending surgeon. I wonder what
would have occurred if I would not have not persistently
questioned the feeding. Would the error been eventually
discovered?
I repeatedly requested an explanation for this error, but
the staff avoided responding to my inquiries. I finally
learned only by looking in my medical records that this
mistake occurred because a verbal order to start oral feeding
intended for another patient was erroneously written in my
chart.
The handling of this incident was an example of a lack of
communication by the physicians and me. They failed to
explain and apologize for the mistake. Accepting responsibility
for the mistake and outlining what steps should be
taken to prevent such mishaps in the future would have
been the most appropriate way of handling the incident.
Errors in Nursing Care
Some of the errors by nursing and other staff included the
following: not cleaning or washing their hands, not using
gloves when indicated, taking an oral temperature without
placing the thermometer in a plastic sheath, using an
inappropriately sized blood pressure cuff (thus getting
alarming readings), attempting to administer medications
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