Proceeding With Caution

"It's important that this information be collected ... because that's the only way we can get a handle on the big threats to the system. We continue to find new ways in which the system has potential lapses, or potential ways it can fail, which just raises the ongoing challenge to eliminating these kinds of events."
Ross Baker, University of Toronto health-policy professor

Most people enter hospitals as a last resort to managing their health. Emergencies take people to hospital settings. Poor health outcomes as a result of genetic inheritance, age, lifestyle, accidents and just plain bad luck on occasion. And then there are life's torments when we are diagnosed with a malady, a disease, a condition for which there is no cure, but there does exist a protocol with the use of prescription drugs and full attention to strict doctors' orders that will permit one to live an almost-normal life.

How many people fully understand when they enter a hospital that it is not the presumably sterile place they believe it to be, nor are accidents and inappropriate actions forbidden to take place where ordinary human beings with acquired professional skills operate and occasionally commit errors that will impact in the most deleterious way to their charges? Air-borne viral agents, transmissible bacteria, moulds, and germs leading to other diseases are rampant in hospital settings.

How could it be otherwise? Hospitals are places full of people seeking medical support for their ills, and they bring with them infectious agents capable of spreading their malign effects among those not affected until they suddenly are. Sometimes those infections are life-threatening, sometimes only complications to an already-health-compromised immune system, with far-reaching effects the patient will be destined to struggle with forever.

Of course 'forever' is a relative term; something is bound to overcome our resistance to death eventually. And sometimes, in a hospital setting, it can be something as unpredictable as a patient's trust that the health professional servicing them knows what they're doing. Sometimes they don't. Sometimes a nurse is confused, too harried to read instructions properly, or reaches for the wrong medication, or gives too much of the right drugs.

A report has just been released divulging the occurrence of 36 incidents over the last year where medication-related errors led to hospital patients suffering severe harm, and on occasion death. Errors in health care can result in truly devastating effects for the unfortunate. Sometimes they're fortunate not to know, because they've expired as a result of those devastating effects. But their loving relatives know, and they mourn.

Ross Baker, a University of Toronto health-policy professor, one of Canada's leading experts on "adverse events" co-authored a landmark 2004 study estimating preventable adverse events with respect to surgery, drugs and other hospital treatment. The result of his study was to identify between 9,200 and 24,000 deaths a year due to those inadvertent incidents.

The Institute for Safe Medication Practices which produced the new report that Ontario mandated a year ago summarized information submitted by hospitals to the Canadian Institute for Health Information between October 2011 and December 2012. Opiods (drugs like hydromorphone, oxycodone and fentanyl) were found to have accounted for over a quarter of the adverse incidents. Blood thinners like heparin were responsible for 13% of cases. And adrenaline-like drugs and anesthetics among six other classes of drugs each accounting for about 7% of incidents.

Administering incorrect medication, dispensing the wrong number of dosages, giving patients medication at the incorrect rate all contributed to seriously bad outcomes, representing the major reason blamed for errors in treatment protocols. One case was described of a patient meant to receive 0.2 to 0.4 milligrams of hydromorphone every hour for pain. Accidentally he was given a 4-mg dose which took his life.

Confusing packaging where medication names are similar, a "look-alike, sound alike" issue has been identified as a danger. Health Canada screens new drugs in an attempt to ensure their names and labelling are not too similar to effectively result in such errors. By identifying these problems and their outcomes, it becomes possible to take remedial action in many areas, minimizing as much as possible, the disastrous errors and their outcomes.