It is important to perform regular records review to detect and correct errors, and it is equally important to counsel, reprimand and educate staff who make errors. You need to be straightforward about this problem, to the point of dismissing those who habitually make medical errors.
Itzhak Brook, MD, MSc
In a whispered but resolute voice, Itzhak Brook, MD, MSc, led off his presentation at the 2012 ASCO Annual Meeting1 by telling the audience his voice is weak because he doesn’t have vocal cords. He spoke with the aid of a tracheoesophageal voice prosthesis. “I have practiced medicine for more than 40 years. After I was diagnosed with neck cancer, I was left shaken, seeing firsthand how common medical errors are,” Dr. Brook said, adding that as a cancer patient, he encountered at least one or two errors a day, running the gamut from minor to life-threatening.
When Doctor Becomes Patient
Dr. Brook, Professor of Pediatrics and Medicine, Georgetown University School of Medicine, said that after the hospitalization following his laryngectomy, he was emotionally unprepared to change roles from doctor to patient. “I had to deal with pain and weakness and being completely dependent on others. On top of that, I couldn’t speak, which compounds anxiety because I couldn’t convey the extent of the problems I was having,” Dr. Brook said.
Dr. Brook pointed out that timely and thoughtful patient-doctor communication is a vital component in preventing medical errors that, as he witnessed, occur with similar frequency at all levels, from nurses to physicians. Moreover, patients are often reluctant to complain to the people they are dependent on. “Laryngectomees are even more vulnerable because they are less able to abort medical errors, given their inability to speak,” Dr. Brook said.
In Dr. Brook’s case, the first, and arguably most serious medical error he encountered was a failure to detect his cancer. “This serious error was probably the result of a failure to do the correct ENT examination that would have revealed the cancer. It was a resident who finally found the cancer,” Dr. Brook said.
“The surgeon also made a serious error when he attempted to remove the cancer,” he added. “During the surgery, he inadvertently removed scar tissue, mistaking it for the tumor. And by not checking the tissue in the OR with a frozen section, it was a week later before the pathology lab identified it to be scar tissue and not cancer,” Dr. Brook noted.
According to Dr. Brook’s experience, nursing errors can include not responding to calls, not washing hands or using gloves, not placing the oral thermometer in a plastic cover, or administering an incorrect medication dose.
“As a patient—especially one who is a doctor—it is very frustrating to realize that errors occur so frequently. I actually needed to become my own watchdog, waiting to catch mistakes, which meant I could never relax. I also realized that in most cases, there was no self-recognition of these errors.… Once, when I was in the ICU, the nurse forgot to connect me to the call button and I was choking, helpless because of her oversight. I was in plain sight of a nursing station—yet no one came to my help until my wife walked in,” Dr. Brook said.
“Instead of administering my medication through the NG tube,” Dr. Brook continued, “sometimes the nurse would try to give me the meds orally, causing me to choke, or administer medication that was dissolved in hot water, burning my esophagus.”
Preventing Medical Errors
As common as medical errors are, Dr. Brook’s observations as a patient left him confident that better and more uniform training and adherence to established standards of hospital care could avert the majority of harms from errors. “It is important to perform regular records review to detect and correct errors, and it is equally important to counsel, reprimand and educate staff who make errors. You need to be straightforward about this problem, to the point of dismissing those who habitually make medical errors,” Dr. Brook said.
He pointed to recent data indicating that developing and following algorithms, use of set procedures, and meticulously following a bedside checklist for all procedures markedly decreases the chance of errors. Dr. Brook commented, “Increased supervision and communication between health-care providers serves as a firewall to errors. Moreover, we need to spend more time educating patients and caregivers about medical conditions and treatment plans. This way they can participate in preventing medical errors.”
Be Your Own Advocate
Dr. Brook’s travails within the hospital system reinforced the need for self-reliance on the part of the patient. In other words, it’s your health—be an assertive advocate for yourself. “You decrease the chances of being the victim of a medical error by being informed and not hesitating to challenge health-care providers and ask for explanations. Become an expert on your condition and how the care should be delivered,” he said.
According to Dr. Brook, an area that needs special attention is postsurgical care. “Educating the patient and family about the short- and long-term implications of surgical procedures is vital. To that end, make sure that the surgical team provides personal attention and spends time giving patients and caregivers information,” he said.
Dr. Brook continued, “I would say to very busy surgeons, as challenged for time as you are, you need greater vigilance and communication among the staff to avoid medical errors. Plus, it’s important to understand the need for better medical and psychological postsurgical care, especially for patients who have had major surgery.”
Dr. Brook concluded his presentation with a brief note about a book he wrote, My Voice—A Physician’s Personal Experience With Throat Cancer, detailing the physical and emotional difficulties of vulnerable cancer patients, especially when their care is compromised by a slew of preventable medical errors. “I would stress to all clinicians that the solution to dangerous medical errors is in their hands. By increasing their awareness and vigilance, they will radically decrease the likelihood of medical errors.” ■
Disclosure: Dr. Brook is the author of My Voice—A Physician’s Personal Experience With Throat Cancer. For more information about the book, visit http://dribrook.blogspot.com/.
1. Brook I: Medical errors in cancer care. 2012 ASCO Annual Meeting. Presented June 3, 2012.