2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

y mouth that were intended to be given by nasogatric tube,
dissolving pills in hot water and administering them
through the feeding tube (which caused burning in the
esophagus), delivering an incorrect dose of a medication,
connecting a suction machine directly to the suction port in
the wall without a bottle of water, forgetting to rinse away
the hydrogen peroxide used for cleaning the tracheal breathing
tube (thus causing severe irritation), forgetting to connect
the call button when I was bedridden and unable to
speak, and forgetting to write down verbal orders.
I always informed the nurse supervisors and whenever I
could the resident and/or attending physicians about the
mistakes that were made; however, I was never informed
what action was taken to prevent similar errors in the
future.
Conclusion
One of the key recommendations to prevent medical errors
is that patients should choose, whenever possible, experienced
places that deal with their kind of disease regularly.
Such familiarity and experience can reduce the occurrence of
errors and increase the safety of the patient. The way a
patient can contribute to the prevention of medical errors is
to be proactive and take these steps: be informed and not
hesitate to challenge and ask for explanations; become
knowledgeable about their medical condition; have family or
friends serve as an advocate in the hospital; get a second
opinion when making an important decision, such as deciding
on the course of treatment; and educate the medical
caregivers about their condition and needs (prior to and
after surgery).
All of the errors made in my care make me wonder what
happens to individuals without medical background who
cannot recognize and prevent many errors. Fortunately,
despite the errors made in my care, I did not suffer any
long-term consequences. However, to prevent medical errors,
I had to be continuously on guard and vigilant, which
Author’s Disclosure of Potential Conflicts of Interest
Author
Itzhak Brook*
*No relevant relationships to disclose.
Employment or
Leadership
Positions
Consultant or
Advisory Role
1. Tezak B, Anderson C, Down A, et al. Looking ahead: the use of
prospective analysis to improve the quality and safety of care. Healthc Q.
2009;12:80-84.
2. Griffen FD, Turnage RH. Reviews of liability claims against surgeons:
what have they revealed? Adv Surg. 2009;43:199-209.
3. Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and
e30
was a very exhausting chore, especially during the difficult
recovery period.
My family members were instrumental in preventing
many errors, highlighting the value of a dedicated patient
advocate. My experiences taught me that it is essential that
medical personnel openly discuss with their patients the
mistakes that were made in their care. Since errors in
patient care weaken patients’ trust in their caregivers,
admission and acceptance of responsibility by the care
providers can rebuild trust and re-establish the lost confidence.
The establishment of a dialogue among patients,
physicians, and other staff facilitates the discovery of the
circumstances leading to the mistake, which assists in
preventing similar ones in the future. Open discussion can
reassure the patient that their care givers are taking the
matter seriously and taking steps to make hospital stays
safer for patients.
Avoiding the discussion of the errors with the patient and
their family only increases anxiety, frustration, and anger.
This can interfere with the patient’s recovery and contribute
to malpractice law suits.
Medical mistakes should be prevented as much as humanly
possible. Ignoring them can only lead to their repetition.
Medical errors usually involve problems in caring for
and treating patients and are improved if the processes are
improved and a blame-free reporting mechanism is instituted.
The recent development of a mandatory bedside
checklist is a simple, cost-effective method to prevent many
medical errors. 4
I am sharing my personal experiences in the hope that
they will encourage better medical training, contribute to
greater diligence in care, and increase supervision and
communication between health care providers and their
patients. It is my hope that this presentation and article will
contribute to the reduction of medical errors and create a
safer environment in the hospital setting. It is also my hope
that if mistakes do happen, medical caregivers will openly
discuss them with their patients.
Stock
Ownership Honoraria
REFERENCES
Research
Funding
Expert
Testimony
ITZHAK BROOK
Other
Remuneration
compensation payments in medical malpractice litigation. N Engl J Med.
2006;354:2024-2033.
4. Byrnes MC, Schuerer DJ, Schallom ME, et al. Implementation of a
mandatory checklist of protocols and objectives improves compliance with a
wide range of evidence-based intensive care unit practices. Crit Care Med.
2009;37:2775-2781.