Medical errors affect 1 in 13 (Canada)

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Medical errors affect 1 in 13

Hospital study first for Canada

Finds high rate of `adverse events'

May 23, 2004. 08:05 AM

 

KAREN PALMER

PUBLIC HEALTH REPORTER

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One in every 13 patients treated in hospital is at risk of suffering an

unintended injury or complication that results in death, disability or

delayed hospital discharge, according to the first study of " adverse

events " in Canadian hospitals.

 

About 185,000 patients are harmed while being treated in hospital each

year, with between 9,000 and 24,000 patients dying after experiencing a

surgical accident or medical oversight.

 

The numbers are probably an underestimate, said Dr. Peter Norton, co-author

of the research and head of the faculty of medicine at the University of

Calgary.

 

A hospital chart review won't catch events that are caused in hospital but

caught at home, or injuries treated later in a doctor's office or walk-in

clinic, he said.

 

Some serious adverse events found in a review of charts included delayed

diagnosis of cancer and heart conditions; drug overdoses; inadequate or

faulty equipment or devices such as pacemaker batteries; insufficient

monitoring by doctors or nurses; patients discharged too soon;

communication errors and surgical mistakes, such as nicking other organs

during a procedure.

 

Researchers figure almost 40 per cent of the incidents could be avoided.

Hospitals need to change their culture of blame before they can fix the

problem, said Wendy Nicklin, a founding board member at the Canadian Public

Safety Institute.

 

" Individuals aren't going to report if they think there's going to be

finger-pointing, " she said.

 

" I think that cultural changes are at the root of where we need to go to

improve health care and improve the performance in patient safety, " said

Ross Baker, a co-author of the study, which appears this week in the

Canadian Medical Association Journal.

 

" The fear that health professionals have that what they do will lead to a

lawsuit leads to a tendency to cover up rather than report things that go

wrong, " said Baker, an associate medical professor at the University of

Toronto.

 

Canada's rate of hospital-related error is double that of the United

States, where two studies showed an adverse-event rate of roughly 3 per cent.

 

However, the U.S. studies were looking for major events that could lead to

a lawsuit, Baker explained. Canadian and European studies included minor

events that could shine light on systemic errors that lead to medical

mistakes, he said.

 

" In a strange sort of sense, this is good news. Events are being looked at

and reported, " said Hilary Short, president of the Ontario Hospital

Association.

 

" Unfortunately, we know these events happen, and people should know, too,

that hospitals are moving forward with quite significant changes and

reforms, " she said. " People should get accustomed to hearing about adverse

events because of the reporting back to patients. But people should not be

concerned. "

 

Researchers scoured 3,745 patient charts for medical and surgical patients

treated in 2000 in 25 hospitals — four community hospitals and one large

teaching hospital in each of Ontario, British Columbia, Alberta, Quebec and

Nova Scotia.

 

They identified 1,133 injuries or complications in 858 patients, and

decided 401 patients suffered a delayed discharge, disability or death

while receiving hospital care. Fifteen patients were left permanently

disabled, and 40 patients died.

 

" These are vulnerable people, many of them quite ill ... and some of them

would have died anyway in hospital as a result of their illness. Their

adverse event didn't help them, but we're not saying there's a causal

relationship here between the adverse events and the deaths that occur in

Canadian hospitals, " Baker said. " Some of those patients would have died

anyway. "

 

Some examples of serious errors: A patient's kidney failure was worsened by

renal toxicity related to the multiple medications that were prescribed. A

patient died because high blood potassium levels went untreated, causing a

heart attack. A blood transfusion administered too quickly resulted in

congestive heart failure. And a woman had her ovaries removed during a

hysterectomy, even though her consent form said they would be left.

 

A patient who survived an adverse event spent, on average, an extra six

days in hospital.

 

Teaching hospitals had a slightly higher rate of adverse events, a fact the

researchers attributed to the complexity of cases treated at those hospitals.

 

" When we looked at what events could have been prevented ... the

differences were not there, which suggests, despite the complexity of care,

teaching hospitals do a similar job in providing quality care, " Norton said.

 

Older patients were more likely to suffer an adverse event, probably

because they have more complex illnesses, " and so we tend to do more things

— they have more tests, they have more drugs and they stay longer in

hospital. All of that contributes to this, " Norton said.

 

Training on how to check or prevent errors begins in the classroom, said

Wayne Hindmarsh, head of the University of Toronto pharmacy faculty.

 

" Accuracy is so important in the training of our students, " he said. " The

medications are getting so precise for what they can do, and people are on

a lot of medications, so it's very important to teach them about drug

interactions and to teach them about monitoring for drug interactions. "

 

Hospitals are already experiencing a shift toward owning up to medical

errors, as seen in recent announcements involving the improper cleaning of

diagnostic tools at Lakeridge Health Centre in Oshawa and Toronto's

Sunnybrook and Women's College Health Sciences Centre.

 

The mea culpas led to a system-wide audit and the revelation that other

hospitals had problems sterilizing equipment. In March, the province

announced it would fund a Patient Safety Support Service to give hospitals

the latest information on best practices, procedures and technologies, such

as electronic medical records, that can minimize mistakes.

 

Doctors and nurses need to take the time to communicate and co-ordinate

care better between shifts, Baker added.

 

" We have to focus on ways we can improve the transfer of information

between physicians and nurses who work different shifts, improve the

interaction between different disciplines — between pharmacists and nurses,

pharmacists and doctors — so we can ensure the right medications, the right

treatments, are provided in a timely way to patients. "