Learning from errors is a painful part of healthcare

Providers know system is flawed, says Owen Heisler.

As a physician, I am all too aware of the risks involved in our efforts to provide the best of care. Sometimes, in efforts to provide compassionate care with the intent to heal, outcomes may not be what we wanted.

Even in hospitals. People fall. People get infections or pressure ulcers. People may not get the right medication at the right time. Harm in the course of treatment is quoted by some as the third most common cause of death in the United States.

Statistics aside, each of these events or nearevents involves a real person and a real family. The hurt and lack of trust that follows is even more tragic.

As the health system struggles with these realities, our response has changed. We used to try and find someone or something to blame. Especially knowing it is very rare anyone intends harm, this has not worked well. We have learned that by reviewing incidents and hearing the stories of those impacted in a non-blaming way, we can find better ways to improve the system.

In Alberta Health Services (AHS) and Covenant Health (CH), we regularly track and review these kinds of events to see how we could improve. Reporting openly is at the heart of a just and trusting culture.

The Health Quality Council of Alberta (HQCA) is doing an excellent job promoting and embracing a just culture in health care, building on their review of Greg Price’s tragic journey through the health system.

Greg was a 31-year-old Alberta man who died on May 19, 2012, three days after surgery to remove a cancerous testicle.

A 2013 HQCA report detailed multiple breakdowns in the quality and continuity of his health care and came up with 13 recommendations.

The Price family and HQCA have been visionary advocates for positive reform, encouraging all of us to learn from Greg ’s journey and other such stories to make things better.

Human suffering is a central factor in medical assistance in dying (MAID), which has had profound personal, institutional, and system impacts since its introduction. For CH, this has been a learning journey involving a deep question explored with a great sense of responsibility: How do we best support patients and families with compassion and respect who choose and have a right to an option inconsistent with our beliefs?

Early in our MAID experience, there were instances where we did not perform as we would expect of ourselves.

The media recently reported on aspects of these events. We had already reviewed these events and worked with AHS to create better processes for meeting legal requirements for assessments while responding with compassion and respect.

As a team, we recognized we made missteps that resulted in distressing experiences for both those we served and the teams who cared for them. We felt for those impacted. We learned.

While the reporting of these historical MAID events feels painful, re-examining events gave us new opportunities to reflect, learn and improve. While providing MAID at our sites is not an option, we determined we could do better in supporting patients and families access to services they wish in a respectful and compassionate manner.

As has been reported, we are continuing to evolve our policies in consultation with multiple stakeholders. To our knowledge, for at least the last year, the process has been working without incident in responding to people seeking access.

The pain and suffering from errors in health care can have lasting personal impact — mostly for the families but also for those of us providing care. As a physician, I know there are multiple factors and perspectives in all stories of less-than-ideal health-care experience.

I also know there is healing needed on so many sides. We must continually reflect, learn and continue to care.

I am grateful for the incredible people in our organization and our health-care system who come to work each day to help those in need and each other.

They come to work in a system that is not perfect as each of us is not perfect.

As Covenant Health, we pledge our commitment to a just and learning culture, looking toward an integrated system that works for all Albertans and enables our dedicated teams to do their best each day.