Ruminations

A Health Report on Canadian Health Care

"Learnings [sic]from these things, even when a good investigation is done, are going into black holes."
"They've created this perfect, invisible box to put everything in."
Was that information [wrong-size metal stent used] ever shared up the street at the next hospital? No it wasn't."
"Because whatever happens within the hospital is a secret within the hospital. And the people who have regional authority to share information, they don't."
Darrell Horn, critical incident investigator

"You have to tell people that patients are getting hurt. 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."
Dr. Rob Robson, Winnipeg health authority's patient safety program

"I wouldn't even want them [two Ontario hospital surgeons] to touch my dog."
"We do turn a blind eye and walk away. There is a lot of lying, there's a lot of coverup, which turns my stomach."
(anonymous) Ontario hospital nurse

"Nurses are very, very cautious about raising issues, blowing the whistle."
"If they were part of ... the adverse incident, they are going to feel like they'll be blamed. It's a heavy, heavy burden to take on. Sometimes it's just easier to keep quiet."
Andy Summers, emergency-department nurse, Toronto

Research concludes that roughly 70,000 patients annually experience preventable, serious injury resulting from medical treatments. A study published ten years ago estimated that as many as 23,000 Canadian adults die on an annual basis as a result of preventable "adverse events" in acute-care hospitals alone; by no means the total of those for whom medicine and hospitalization has failed.

There is some evidence to suggest that despite the millions in funding spent on patient-safety efforts that toll has increased, if anything. Despite which it is a mere fraction of the numbers that are given public acknowledgement in the form of statistics. Most of the medical treatment errors leading to injury, longer hospital stays, health complications or death are incidents that never see the light of critical inquiry.

In Manitoba, a new mother experienced a heart attack when hospital staff erroneously gave her blood-pressure-increasing medication rather than the required nausea antidote following a caesarean section. A patient whose risk for blood clots was known, suffered a fatal cardiac arrest when hospital staff overlooked the need to provide preventive treatment post-surgery.

In another case a woman required a second operation once it was discovered through an
X-ray that a screw from a broken clamp used during the first surgery had been left inside her during a C-section. One patient erroneously "underwent unnecessary open-lung biopsy." These are a handful of red-flagged and critical errors that the Province of Manitoba had responsibly high-lighted.

In most provinces legislation presents a roadblock to information on medical/hospital adverse events released to malpractice plaintiffs, or to be publicly divulged under freedom-of-information acts. What is meant to take place is that internal reporting of errors are encouraged. Instead, nothing much of note-taking and discussions leading to efforts to share cautions based on best-practices and avoidance of errors does in fact take place.

One nurse filed an anonymous complaint against two surgeons she worked with in the operating theatre who were clearly lacking critical skills. Nothing resulted from her complaint. She's learned her lesson, and her concerns revolving around high rates of post-operative infections, to failed surgeries requiring repeats, remain with her, and while she deplores the status quo, she fumes silently.

Patient-safety experts point out that it is in the interests of creating awareness and a better system that medical errors should be publicized, not for the purpose of blaming or shaming health professionals. They agree there are a handful of incompetent doctors, but for the most part physicians and surgeons are dedicated to good patient care. Often complex situational issues are at play, and in those instances their outcomes should be regarded as learning experiences.

The prevalence of medical errors in Canada is a shadowy issue, with substance but without numbers. In examining patient charges at a representative sampling of 20 acute-care hospitals researchers discovered that 7.5% of adult patients (185,000 yearly across the country) were exposed to a serious adverse event. Of that number 40% were of a preventable nature.

The mortality element is grave; between 9,000 and 23,000 patients die from preventable error, annually, the researchers spearheaded by the University of Toronto's Ross Baker and University of Calgary's Peter Norton in 2004, concluded. Eight years later a similar study examined pediatric patients to discover the rate of children harmed by adverse events was higher even, at 9.2%/

Since then, it is posited, the numbers may have risen according to Hugh MacLeod, chief executive of the Canadian Patient Safety Institute. "With the pace, the increase of new technology, new drugs, new approaches ... the probability of risk and incident has grown", remarked Mr. MacLeod.

None of the studies included psychiatric and obstetric patients and residents of nursing homes and chronic-care hospitals, leaving the true number of preventable deaths likelier in the area of 35,000 annually. The equivalent of four occurring every hour, remarked Dr. Robson. There was one report recommending cardiologists put a stop to playing music in the operating room; it causes distractions and distortions in directives.

Sometimes health workers are reluctant to expose errors because in fact they don't notice these issues when critically ill patients are involved. On the other hand, they fear being blamed should they report an error or sense that reports are simply ignored when they're filed.