(Canada) Report details medical error horrors

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(Numerous reports in this message, first from the Globe and Mail, second

from The Toronto Star, third the earlier 'generic' one from Canadian Press

- note the similarities )

 

Report details medical error horrors

http://www.theglobeandmail.com/servlet/ArticleNews/TPStory/LAC/20040610/ERRORS10\

/TPHealth/

 

Adverse events have led to 1.1 million added days in hospital per year,

researchers say

 

By ANDRÉ PICARD

PUBLIC HEALTH REPORTER

Thursday, June 10, 2004 - Page A21

 

Treating people who fall prey to medical errors gobbles up more than 1.1

million hospital days and adds a whopping $750-million to the country's

health-care bill each year, a new study suggests.

 

The news follows on the heels of a groundbreaking study revealing that one

in every 13 medical/surgical, acute-care hospital patients suffers from an

" adverse event, " and that these failings, avoidable and otherwise, kill up

to 24,000 Canadians annually.

 

The new report, released yesterday by the Canadian Institute for Health

Information, provides graphic details on the woes befalling patients.

 

The data show that: one in nine adults contracts an infection while in

hospital, ranging from pneumonia to SARS; one in nine patients receives the

wrong medication, or the wrong dose; one in 20 women suffers severe tearing

during childbirth; one in every 81 babies born vaginally suffers trauma,

emerging with injuries such as a broken shoulder; one in every 299 patients

receiving a blood transfusion will have a reaction; one in every 1,124

adults over the age of 65 suffers a broken hip during a hospital stay; one

in every 6,667 surgery patients will have a foreign object left in his or

her body after the procedure.

 

" Like nuclear energy and aerospace, health care is a complex environment

where errors can maim and even kill, " said Jennifer Zelmer, vice-president

of research and analysis at CIHI. She said about one-third of adverse

events are preventable.

 

While the vast majority of patients recover quickly, Ms. Zelmer said the

additional resources required to deal with medical errors is substantial.

Patients who suffer harm often have their hospital stays prolonged. While

unable to provide a detailed cost breakdown, she said a conservative

estimate of the cost of 1.1 million hospital days of care would be about

$750-million.

 

Adverse events are unintended injuries or complications caused by

health-care management, not by the underlying disease.

 

Sav Rosenberg, 61, of Laval, Que., knows all too well the cost. On Feb. 26,

he was admitted to Jewish General Hospital for a routine prostate operation

but, just before discharge, he contracted a bacterial infection,

Clostridium difficile.

 

" I was supposed to stay, originally, for three days. I ended up 24 days in

the hospital and I'm still sick, " Mr. Rosenberg said. He has only recently

been able to return to work, driving a cab. Still, he was a lucky one; at

least 79 patients have died of the virulent infection in recent months.

 

Mr. Rosenberg said he had " no idea " he could get sick in hospital.

 

John Wade, chairman of the new Canadian Patient Safety Institute, said this

anecdote demonstrates there is a lot of work to be done in improving both

patient safety and patient education.

 

" This report provides us with valuable information on the incidence and

magnitude of adverse events. Now it's time for action, " he said.

 

But Dr. Wade, an anesthesiologist, cautioned that patients have to be

realistic. " We're aiming for zero, but we will never get to zero; we will

never eliminate error or adverse events completely. "

 

He also said the numbers have to be kept in perspective. There are about

2.5 million admissions to acute care hospitals in Canada annually. About

187,000 patients suffer from adverse events. Of that number, between 9,250

and 23,750 died in 2000 after a failure in their treatment. (This does not

imply that the medical error was directly responsible for their death,

because many hospital patients are already acutely ill.)

 

Michael Decter, chairman of the Health Council of Canada, said that

reducing the number of adverse events must be a priority because it

undermines faith in the health system, and adds substantial costs.

 

He also suggested that the Canadian public is too tolerant of failings in

the health system. " Were we in any other industry, facing a problem of this

magnitude, I suspect there would be enormous public consternation, " Mr.

Decter said.

 

But he was quick to add that the solution is to give health professionals

the tools to improve care, not persecute them when things go wrong, often

inadvertently.

 

" This is a massive problem that's going to have to be dealt with by

thoughtful effort, not by blaming people, " he said. Mr. Decter said one

approach that should be seriously considered is no-fault insurance for

patients who suffer from adverse events.

 

The new research on adverse events was just one element of the fifth annual

report of the Canadian Institute for Health Information. The CIHI is an

independent, not-for-profit organization mandated to improve the health of

Canadians and the health-care system by providing quality health information.

 

Frequency of complications in hospital

 

There are roughly 2.2 million patients discharged from hospital a year in

Canada. A national estimate of the average number of Canadians who receive

care or are exposed to a risk per adverse event:

 

1 in 9 adults with health problems reported being given the wrong

medication or dosage by a doctor, hospital or pharmacist in the past two years.

 

1 in 16 reported an adverse event for themselves or a loved one in the past

year.

 

1 in 152 deaths are associated with preventable adverse events for

medical/surgical patients in acute care hospitals.

 

1 in 1,124 people over age 65 suffered in-hospital hip fractures.

 

1 in 6,667 had a foreign object left in their body after a surgical procedure.

 

1 in 72,046 got infected with hepatitis B from a blood transfusion.

 

1 in 10 million got infected with HIV from a blood transfusion.

 

SOURCE: CANADIAN INSTITUTE FOR HEALTH INFORMATION

 

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Drug errors affect 1 in 9 patients

Report details health care statistics

Electronic prescribing eyed as solution

Jun. 10, 2004. 10:33 AM

 

KAREN PALMER

PUBLIC HEALTH REPORTER

 

Canadians put themselves at risk of infection, broken bones or drug mix-ups

every time they set foot in hospitals, doctor's offices or local

pharmacies, according to a report released yesterday by the Canadian

Institute for Health Information.

 

" I think anytime anybody enters a hospital or they seek care, there's a

potential for infection and there's a risk. Some of it is very minor, some

of it is major, but there's always a potential risk, " said John Ward, chair

of the Canadian Patient Safety Institute.

 

" We will never eliminate error or adverse events completely, but we can

certainly reduce the incidence, " he said.

 

The report found that one in every nine Canadians received the wrong

medication or a drug overdose while getting medical care in the past two years.

 

Graphic: What can go wrong

About 5.2 million Canadians also say they or a family member were harmed

while receiving medical help, resulting in injuries that sent them to

hospital, prolonged their stay or ended in disability or death.

 

 

" No matter how you slice it, it's a very high number and it's one that

causes great concern, " said Dr. Michael Decter, chair of the Canadian

Health Council.

 

The report builds on a ground-breaking study released last month, showing

that one in every 13 patients treated in hospital falls victim to a medical

error.

 

Yesterday's report paints an even more detailed picture of medical mishaps

that can happen in hospital, at the doctors' office or the local pharmacy.

 

The report found that one in every nine adult patients and one in every 11

pediatric patients treated in hospital picked up an infection like pneumonia.

 

One in every 20 mothers giving birth suffered a third- or fourth-degree

tear while delivering and the babies themselves suffered traumatic events,

like a dislocated shoulder, at a rate of one of every 81 deliveries.

--

One in every 11 children pick up an infection like pneumonia while in hospital

--

The report also looked at falls and fractures amongst elderly patients and

the number of times a foreign object, like a sponge or surgical instrument,

was left inside a patient.

 

The human cost is enormous, Decter said, and the health system suffers as

well. Experts are looking to electronic solutions, including electronic

patient records that would store information on drug allergies, as well as

electronic prescribing, which would better track drug history and help

prevent overdoses.

 

" No drugs are absolutely safe. There's a risk associated with all drug

therapy, " said Jeff Poston, executive director of the Canadian Association

of Pharmacists.

 

However, he said health care providers like doctors, nurses and pharmacists

need to talk to each other and include each other in the decisions made

about a patient's care.

 

More important, Decter said, hospitals and health workers need to move away

from a culture where every mistake could mean a lawsuit.

 

" This is a massive problem which is only going to be dealt with by very

thoughtful effort, not by blaming people but by finding a way of bringing

the errors out into the open so we can find better ways of doing things, "

he said.

 

Hilary Short, president of the Ontario Hospital Association, agreed.

 

" The key is that they are trying to create a culture in hospitals where you

don't assign blame when something happens. You want a situation where

people don't cover up adverse events. You find the problem and fix the

system so it does not happen again, " she said yesterday.

 

Short said she had not yet seen a copy of the study, but had heard reports.

 

" Patient safety is job number one in hospitals, " she said.

 

" Yes, adverse events do occur, but hospitals are learning more each day how

to prevent such events from happening.

 

With files from Philip Mascoll

 

===================

The generic " Canada Press " article:

Medical errors consuming up to 1.1 million hospital bed days a year: report

 

HELEN BRANSWELL

Canadian Press

 

Wednesday, June 09, 2004

 

TORONTO (CP) - Patients who have experienced medical errors are clogging up

a huge number of hospital beds every year in Canada, potentially absorbing

as many available beds as all women going through pregnancy and childbirth,

a new report suggested Wednesday.

 

As many as 1.1 million hospital days may be attributable to correcting

problems caused by so-called adverse events, the Canadian Institute for

Health Information said in its annual report. In addition to endangering

the lives and health of people, adverse events are draining badly needed

resources from the overtaxed system, said Dr. John Wade, the chair of the

Canadian Patient Safety Institute.

 

" I think there's a huge economic argument to be made that that's costing

the system billions of dollars and that if we could prevent some of that,

rather than patient safety (initiatives) costing the system, it should save

the system, " Wade said in an interview.

 

" And those monies could be reinvested in (reducing) wait lists or whatever. "

 

The number of hospital days was calculated using data taken from a recently

released landmark study which sought to establish for the first time the

rate at which things go wrong in hospitals and what impact that has on the

patients.

 

That study, by Prof. Ross Baker of the University of Toronto and Dr. Peter

Norton of the University of Calgary, found that one in 13 people

experienced an adverse event while in hospital and that the medical error

added on average six days to their hospital stay. The CIHI report

extrapolated that to reach the 1.1 million hospital days figure.

 

The Baker-Norton report also found that preventable errors may be

contributing to between 9,200 and 24,000 deaths a year - a range the

experts at Wednesday's report release admitted they found surprising.

 

" No matter how you slice it, it's a very high number. And it's one that

causes great concern and . . . it's urgent to attack it, " Wade said.

 

Michael Decter, who was chair of the institute of health information when

it agreed to co-fund the Baker-Norton study, said he'd initially hoped it

would show the long-accepted estimate of 10,000 preventable deaths was an

exaggeration.

 

" So this is a massive problem which is only going to be dealt with by very

thoughtful effort. Not by blaming people but by finding a way of bringing

the errors out into the open so that we can find better ways of doing

things, " Decter said.

 

The institute helped shed more light on the scale of the problem by

analysing some of its own data, gathered from hospitals across the country,

as well as the released Baker-Norton data and information from other sources.

 

Its analysis suggests:

 

- One in nine adults contract an infection while in an acute care hospital.

The number among children is one in 11. Urinary tract infections, surgery

site infections and pneumonia are the most common of these.

 

- One in 20 women experience third or fourth degree tears during childbirth.

 

- Birth trauma occurs in one in every 81 births. Trauma can range from a

dislocated shoulder to much more serious problems.

 

- One in 1,100 seniors break a hip by falling while in hospital.

 

- One in 6,700 people who have surgery have a foreign object, things like a

sponge or a surgical instrument, left in them during surgery.

 

Some measures are being adopted in efforts to reduce medical errors. Some

hospitals, for instance, require a surgeon to sign a patient's body in a

pre-surgical visit so they'll be sure to cut in the right spot when the

patient reaches the operating room.

 

And studies have shown that electronic record keeping - using computer

programs designed to flag potentially dangerous drug interactions - can

reduce the rate of medication errors. But electronic records have not been

widely adopted as yet.

 

Still, experts believe a culture shift needs to occur in hospitals before

major progress can be made. Surveys suggest health-care professionals are

aware of the problem, but feel pressure to hide mistakes because they fear

being sued.

 

Norton said members of the public have to have the right to sue if they

sustain serious harm from medical errors. But the system needs some

adjustment to ensure that health professionals can openly address the

problem so that they can seek solutions.

 

" In some sense we need to have a correction, a steering correction, " he

said from Calgary.

 

Wade agreed, noting the patient safety institute believes provincial

evidence laws should be changed to allow medical workers to discuss errors

in a " privileged " environment where their comments could not be used

against them later in court. The institute is drafting a template for that

legislative change, he said.

 

That doesn't mean hospitals should be able to hide errors, he insisted.

Most provincial regulatory bodies require errors to be noted on patient

charts and discussed with patients and their families.

 

There's an advantage to hospitals in that, Decter noted. Studies suggest

people who have been told they were the victim of an error are less likely

to sue than those who were not told.

 

Until medical professionals feel free to reveal and discuss errors, the

goal of improving patient safety will remain elusive, Wade said.

 

" If we don't change the culture from one of blame and shame to one of

information sharing and solving the problems, we won't make much headway. "