…”The point of publicizing medical error, patient-safety experts stress, is not to shame or blame, or take away from the fact health care is replete with highly trained, dedicated professionals. Aside from a tiny smattering of true incompetents, no one comes to work expecting to dispense anything but exemplary care, says Rob Robson, a physician who led the Winnipeg health authority’s groundbreaking patient safety program for seven years.
When things do go wrong, it is typically the result of a complex interplay of factors, often involving underlying flaws in the system, he added. Finding ways to prevent those mistakes is, of course, the ultimate goal and subject of intense research and numerous initiatives.
But publicity about error helps both in drawing attention to the issue and providing a well of knowledge, say safety experts.
“You have to tell people that patients are getting hurt,” said Dr. Robson. “As long as the public doesn’t realize that one in 13 people coming into the hospital will experience some kind of adverse event — and that’s the conservative estimate — then there isn’t any pressure to say, ‘Listen, fix these damn things.’ ”
The risk inherent in hiding such information was tragically highlighted in 1997, when yet another child fell victim to a classic medical error, an error some believe still occurs.
Doctors at the B.C. Children’s Hospital administered a series of drugs to Kristine Walker, a seven-year-old whose leukemia had come back. Inadvertently, they injected vincristine — meant for intravenous use — into her spinal fluid. Doctors have known since the late 1960s that using the medication “intrathecally” triggers catastrophic, usually fatal neurological damage.
Kristine became paralyzed and died two weeks later. After her death, the hospital discovered that at least three similar incidents had occurred in other provinces in previous years, reminders of the importance of preventive measures. None were made public or even communicated within the health-care system.
“We were not able to learn from our own mistakes, nor did we have the opportunity to learn from those of our colleagues,” Lynda Cranston, the hospital’s president, lamented at the time.
As long as the public doesn’t realize that one in 13 people coming into the hospital will experience some kind of adverse event — and that’s the conservative estimate — then there isn’t any pressure to say, ‘Listen, fix these damn things.’
Procedures to avoid the error have been implemented widely, but as recently as 2012, the Institute for Safe Medication Practices (ISMP) reported the “worrisome” finding that fewer than 60% of Canadian hospitals applied warning labels on vincristine, one of three key safety measures.
An ISMP alert late last year claimed that while rare the “excruciatingly painful” mistakes still happen.
And yet, outside media reports and a journal paper about the 1997 B.C. case, there remains virtually no public documentation of any Canadian incident.
In reality, no one knows exactly how prevalent medical error is in Canada. The best approximation comes from a widely accepted 2004 study spearheaded by the University of Toronto’s Ross Baker and University of Calgary’s Peter Norton, now known simply as Baker-Norton.
The researchers examined patient charts at a representative sampling of 20 acute-care hospitals. They found that 7.5% of adult patients — which extrapolates to 185,000 a year countrywide — suffered a serious adverse event, almost 40% of which were preventable. Between 9,000 and 23,000 people die annually from preventable error, they concluded.
Eight years later, a similar study looked at pediatric patients, finding the rate at which children are hurt by adverse events was even higher, 9.2%. And, if anything, the numbers may have climbed since, says Hugh MacLeod, chief executive of the federally funded Canadian Patient Safety Institute.
“With the pace, the increase of new technology, new drugs, new approaches … the probability of risk and incident has grown,” he said.
Add psychiatric and obstetric patients, and residents of nursing homes and chronic-care hospitals — none of whom were covered by the two studies — and the true number of preventable deaths is likely in the realm of 35,000 annually. That’s four every hour, says Dr. Robson.
There’s a bitterness, there’s an anger when it’s from medical malpractice, when it’s preventable
Read the full story and related stories via Inside Canada’s secret world of medical error: ‘There is a lot of lying, there’s a lot of cover-up’ | National Post.