Breast Cancer Screening Error: Fatal Mistake or Lucky Case Study 2022

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CASE STUDY: BREAST CANCER SCREENING ERROR: FATAL MISTAKE OR LUCKY
ESCAPE
Name
Intuitional affiliation

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Introduction
The world today is in an era where almost all aspects of human lives are affected by technology.
Education, health, transport, housing, etc. are all at one point or another influenced by
technology. Technology has extensively made life more comfortable by simplifying almost all
human activities. For instance, because of technology, someone can learn from whichever
college wherever they are over the internet, and therefore eliminating all the baggage that comes
distance and geographical barriers1. In the health sector, technology has enabled the detection
and prevention of illnesses that might have been fatal through screening. It has also made it
possible for complicated medical procedures to be carried out successfully. However, technology
is not one hundred percent shielded from error. It requires constant maintenance, and updates;
otherwise, it leads to even more harm than good to the consumers. This study will tackle the
issue of system failure in the screening of Breast cancer2.
Description
The case study, “Breast cancer screening error: fatal mistake or lucky escape?” by Nigel
Hawkes, that was published on May 8, 2018, in the British Medical Journal (BMJ) looks into a
medical error involving cancer screening that occurred for around nine years before it was
discovered3. The screening mistake is said to have occurred as a result of information technology
(IT) system failures such as the cut off for breast cancer screening being set at the age of 70
instead of 71 years. As a consequence, it is estimated that around 225 lives have been lost. The
fallacy was identified by public health England while reviewing its systems4. Public Health
England found out that in the course of the nine years of the AgeX trial, a number of invitations
had not been sent out to women between their 68th to 71st birthdays5. The case study further
points out the reactions of the public to this revelation. Some people feel that the hitch in the

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system led to the loss of the quoted lives, while others think that there wouldn’t have been any
significant change, given that the cancer screening program, and the system thereof, operates on
a three-year cycle. The error is said to be so insignificant to the extent of being overlooked for
almost a decade6.
The technical hitch is discovered nine years after it occurred. It caused an uproar and confusion
in public. The public felt that due to the error people died. Most of them call the Public Health
England for an explanation on how such an error could have remained unnoticed for such a long
period of time. We, however, find some involved parties like Paul Pharaoh, a professor of cancer
epidemiology at the University of Cambridge who were doubtful that the technical hitch resulted
in the mentioned death. Pharaoh opined that there was no way of telling if the outcome would
have been different had the error not occurred or had it been discovered early enough7.
The public health England offered to provide mammography to those women who were not
satisfied with the results. It also promised to put in place measures to ensure that such an
outcome would not be experienced again. This too has however been met with much skepticism.
The president for clinical radiology at the Royal College of Radiologists, Caroline Rubin, for
instance, said that redoing the screening to such a massive number of patients would strain the
already overworked units. Experts in women health have cautioned the public not to undergo the
rescreening claiming that it would just add to their suffering. The experts claimed that the breast
cancer screening trial caused more harm than good to the patients by identifying some harmless
issues and therefore subjecting the patients not only to worry but also the pain of surgery and
other medical procedures designed to “save” them8.

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Discussion
Dispensing health care to patients is one of the most complex processes that require an
integration of different systems. A system can be thought of as a protocol that has been put in
place by an organization to enable adequate delivery of services to consumers. There are many
systems that underpin the processes involved in giving health care to the public. For instance, the
socio-technical theory is paramount to the AgeX trial case study. The socio-technical system is
essential in understanding how technology affects work, in our case, how it affects public
healthcare9. The technological components of the system, such as equipment, technology, and
infrastructure influence the social aspects of the system, such as culture. The changes in
technology have a direct impact on both the technical and cultural and management systems.
In the health sector, many countries have put systems in place with the primary goal of
enabling the public to get medical care with ease and also to ensure that he medical care given is
of the best quality. For example, Better Health Outcomes through Mentoring and Assessment
(BHOMA) 10, is a medical system in Zambia that was created to help remove several barriers that
prevented optimal medical care in the country. The hindrances to medical progress that were
identified in Zambia include poor referral systems, shortage of health infrastructure, inadequate
availability of a qualified human resource, and socio-cultural practices. The BHOMA project
aims at strengthening the health sector, especially in rural Zambia, focusing on three districts of
Chongwe, Kafue, and Luangwa12.
In the United Kingdom, the Public Health Service situated the AgeX trial11, a program that
intended to find out if routine scanning every three years for breast cancer could be extended be
to beyond the age of 70 years12. The program geared at minimizing the mortality rate as a result
of breast cancer in the country.

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The rate at which different countries are setting up systems underlines the importance of systems
in medical care. Systems ensure that the health sector operates smoothly and that the public gets
access to quality medical care. The systems also enable the governments in the allocation of
resources to the health facilities depending on the needs of the public. They help in unearthing
the problems in the medical sector and focusing on how to solve them. In the AgeX trial, the
public health England sort to extend the lives of women and reduce the number of those who
succumbed to breast cancer by carrying out a routine scanning. The scanning was meant to catch
cancer in its infancy stages and therefore facilitate the manner in which a remedy would be
implemented13.
There are different kinds of systems in practice today. Systems could be simple, complicated, or
complex. Simple and complicated systems can be easily understood since they are more direct.
The two types of systems show a direct relationship between an occurrence and its aftermath.
A simple system is, as the name suggests simple and is the most straightforward system to
understand. This system shows a direct consequence of an event in the simplest way possible,
usually in one or two steps. For instance, in the AgeX trial, we are told that the computers were
programmed to send invitations for mammograms to women who were 70 years and below. The
result was that the women who were above 70 years old were excluded from the process.
A complicated system is more intricate as compared to a simple system, though the resulting
effect can be traced to its original cause. The source of an unwanted outcome can be easily
pointed out the difficulty is in the remedy of the problem. Solving a problem in a complicated
system is more involving compared to solving one in a simple system. In medicine, for example,
performing surgery, to remove, say a benign breast tumor, can be thought of as a complicated
procedure. The route of the problem (the tumor) is known, and the remedy (removal by surgery)

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is also known. The method of removing the tumor is, however, much difficult and bears several
risks that could even be fatal.
A complex system, on the other hand, is not direct or predictable, and therefore cannot be
understood by philosophies such as reductionism. A certain level of understanding of the way a
complex system operates can be however, be obtained if one studies it keenly. Complex systems
are usually comprised of many dynamic and interacting variables. Because of the many
interacting variables, a complex system is ultimately unknowable. A hitch in the operations of a
complex system is impossible to pinpoint, and therefore it is impossible to eliminate it. Educated
guesses can, however, be made about the source of the malfunction and therefore a solution to it
found. Most population and public health problems fall under the complex systems’ category.
Systems thinking is an approach to integration basing on the belief that the individual parts of a
system will work or behave differently when removed from the system’s environment or the rest
of the components of the system in question14. It differs from the positivist and reductionist
thinking in that it views systems as an integration of single small systems working together to
achieve a certain goal and that without this synergistic interaction, the result is an entirely
different thing — system thinking advocates for inter-relationships, perspectives, and
boundaries14.
Digital health and health informatics play a crucial role in systems thinking15. Digital health and
health informatics can be simply considered of as “Digital health is about electronically
connecting up the points of care so that health information can be shared securely.”. It
encompasses mobile health, telemedicine, and personalized medicine, wearable devices for
medical purposes, health information technology, and telehealth to provide awareness and
medical care to people with ease. Digital health and health informatics work synergistically in

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providing health care to the population. Without the systematic flow and storage of data, for
instance, the whole medical process is put in jeopardy.
It is imperative to understand that to obtain high-quality health care, every part of medicine,
however insignificant it may seem, is crucial, and that it enough weight to tip the balance either
in favor of quality medicine or a failed health sector16. As the world changes and technology
advances, so do new diseases emerge, and old ones evolve to even more severe forms that are
resistant to conventional medications. To curb such illnesses, we need to change our way of
thinking from unidisciplinary and reductionist to one that is more inclusive of different sectors of
medicine, working together to achieve successful methods of dealing with them, The world,
therefore, is in much need of systems thinking approach to deal with the rising challenges in the
medical field17.
Implementation of the successful systems approach in health care has until now been a
challenging undertaking, despite its increasing recognition, awareness, and support from the
public as a whole. While several factors affect the manner in which health systems achieve
efficiency in dispensing health care, such as the ability to seize opportunities, and continuity of
stewardship, connecting good health and successful health systems has been an arduous
undertaking18. Furthermore, introducing innovations effectively in health systems, and
understanding how the innovations interact with variables within the health systems to influence
the outcomes have been quite problematic. For instance, the lack of compatibility between an
equipment and electricity voltage in a health facility makes it impossible for the equipment to be
used. In the case of AgeX trial in the United Kingdom, the source of the error in breast cancer
screening was not the integration of information technology into the screening exercise, but its
use in facilitating the process.19 According to Jeremy Hunt, the secretary of state for health and

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social care, the cause of more than two hundred deaths was a flaw in the computer algorithms
used in the exercise. The problem in the scenario was a lack of knowledge on the operation of
the technology, which led to the program allowing women aged a maximum of 70 years to
undergo the screening tests. Another challenge is the public view of the system. From the case
study, we see individuals such as Susan Bewley claiming that the AgeX trial only caused more
suffering than good to the patients. Such a response from the public is a limitation to the
successful application of systems thinking in healthcare20.
Conclusion
Technology is a very important part of our daily lives. It has made human life more manageable.
In the health sector advancement in technology has been beneficial in that it has led to many
lives being saved. Cancer screening machines, incubators, X-ray machines, PCR machines, IV
pumps etc. are just a few examples of technology that are used in healthcare today, and without
them, many lives would have been lost. In most cases, technology has been helpful to human
beings. Technology is, however, not always reliable, and in such circumstances, it has led to
fatalities. Technology must be, therefore used with care. It must be well maintained and operated
by qualified personnel to avoid mistakes such as those that happened in the AgeX trial.
Implementation of systems thinking in healthcare has been difficult. Systems thinking in
healthcare has been met by three major problems; the take-up problem, where the acceptance of
the new solution is hard; the diffusion problem, where disseminating the knowledge of the
benefits of the intervention to the entire system is cumbersome; and the sustainability problem,
where the shelf life of the system has to be considered and necessary action taken. The pros of
technology and systems in healthcare, however significantly outweigh the cons.

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Recommendation
It is imperative to understand that systems are complex and resilient, and that these
characteristics must be respected. It is also important to note that change is inevitable and
therefore the health sector and all its affiliations must learn to adjust accordingly. The systems
thinking should therefore be implemented in public HealthCare since it is the only system that
can include all the factors that affect healthcare. Systems may have limitations, which are
outweighed by the pros. We should learn to accept that at some point, in the implementation of
systems thinking in healthcare, fatalities may occur. We also need to know the extent of the
fatalities had systems thinking not implemented. Once we have these facts, we will learn that
systems thinking is the basis upon which high quality healthcare is founded.

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