A review of physician preparedness in response to a systemic crisis: The case of Eastern Regional Health Authority, Newfoundland, Canada, estrogen receptor (ER) breast cancer (BC) errors

Abstract

e17551 Background: From March until October 2008, a Commission of Inquiry was held in St. John's, Canada, investigating systemic errors leading to incorrect ER results in BC patients. 386 ER negative BC samples tested between 1997 and 2005 were incorrect. Of 91 witnesses, 26 physicians testified about their roles in this “crisis.” Physicians have traditionally been trained to respond to individual clinical crises and acute traumatic situations. This study summarizes the physicians’ training and preparedness in response to a systemic organizational crisis. Methods: Inquiry exhibits, submissions, and transcripts of physician testimony were reviewed for evidence of education and experience in crisis management (CM) as applied to a complex organization. Education and experience with organizational health care crisis were tabulated and prevalent themes relevant for physicians summarized. Results: Evidence was reviewed from 5 oncologists, 17 pathologists, 1 health information analyst, and 3 senior physician leaders. 20 physicians held departmental or divisional leadership roles, one had an advanced degree in Public Health and one had direct experience in a complex private organization. 5 out of province expert consultants had direct experience with continuous quality control applied to large organizations. No physicians were formally trained in CM in terms of acute crisis response. Two prevailing concerns were expressed: 1) delayed and incomplete disclosure of information to patients and public, and 2) numerous preceding systems problems identified by physicians that did not translate into necessary systemic changes to prevent the crisis. Conclusions: The practice of CM recognizes the need to eliminate technological and human systems failure and to develop formal communication systems to avoid or to manage crisis situations. Large-scale organizational crisis management is an important concept for physicians to understand and actively participate in their professional roles. At present most physicians do not receive formal training in CM. No significant financial relationships to disclose.