The value of a patient advocate has never been proved more profoundly than in “Right Regimen, Wrong Cancer: Patient Catches Medical Error.” In this case, the advocate was the patient.
The article in the May issue of Web M&M (Morbidity and Mortality Rounds on the Web), published by the Department of Health and Human Services, detailed how a man being treated for metatastic penile cancer prevented a horrible mistake from being made. He was admitted to the hospital for his fourth round of chemotherapy. In the three previous rounds he had received the drugs paclitaxel, ifosfamide and cisplatin each of the three days he had been hospitalized, and had experienced minimal side effects.
On the fourth day of his fourth round, he was expecting, as usual, to be discharged to go home. That morning, a nurse entered his room, and explained that she would be administering his chemo that day. Because this was not the standard routine, he asked to speak with the oncology team before he got the chemo.
An oncology fellow spoke with him, reviewed the orders and realized that two additional days of chemo therapy had been ordered in error. Rather than the three-day regimen for metastatic penile cancer, the order had been given for a higher dose, five-day regimen of paclitaxel, ifosfamide, and cisplatin for germ cell cancer. After the first oncologist conferred with the attending oncologist and discussed the situation with the patient, he was discharged that day.
Close call. Smart patient. Lucky man.
The mistake was formally reviewed. It turned out that the outpatient oncologist (a specialist in penile and germ cell cancers) had recommended the appropriate three-day regimen to the oncology fellow on a paper form, despite the fact that the facility had an electronic health record (EHR) and computerized entry system. The oncology fellow inadvertently chose the wrong paper order set-he saw that the order set included the correct agents but failed to notice the higher dose and incorrect duration.
The inpatient attending oncologist, who did not know the patient and was not a penile cancer specialist, had co-signed the fellow’s incorrect orders. During the patient’s hospitalization, the internal medicine team copied and pasted the original oncology outpatient note for the three-day course of chemotherapy, even though it was different from the five-day regimen that was ordered this time. None of the other safety checks-a chemotherapy pharmacist and chemotherapy nurse checking the orders against allergies, kidney function, etc.-identified the discrepancy.
As the article authors wrote, “The discovery of the error by the patient is notable and the team is to be commended for responding rapidly to prevent additional harm. This ‘intervention of last resort,’ though, cannot be depended upon. Not all patients are attentive, knowledgeable, and brave enough to voice concerns about their care.”
Amen, brother. Oncology care is complicated and risky. Treatment of the life-threatening disease often is toxic itself. Ordering and administering chemotherapy requires expertise and, as the writers say, “meticulous coordination of care.”
Conflict between electronic and paper-based systems is not acceptable in such precarious circumstances. Lack of coordination among oncology team members who specialize in different forms of the diseases is not acceptable. As the articles states, chemotherapy regimens “can involve multiple drugs administered in repetitive cycles, and are adjusted periodically to address toxicities. As the case illustrates, chemotherapy administration is among the more hazardous and challenging activities in all of medicine.”
The message this case sends should be heard by both the professionals providing the care and the patients and their advocates, who must insist on being part of the oversight of their care. For further information, see our two-part newsletter, “Protecting a Loved in the Hospital,” and “A Safer, Healthier Hospital Stay.”