MEDICAL ERRORS
Report: Dangerous breakdown in health-care system.
As Helen Church woke up one morning just before Christmas 2012, the pain that had been building for weeks behind her right eye reached an excruciating climax.
Screaming in agony, she ran around her east-end Toronto apartment before finally managing to call 911 and passing out.
For the second time in short succession, she had fallen victim to health care gone badly awry.
Just two years earlier, Church went to a nearby hospital to have an ovary removed as treatment for a painful cyst. She left hours later with the ovary still in place — and a piece of mesh embedded in her abdomen to repair a non-existent hernia.
Then, months later, a specialist replaced an artificial, cataract-correcting lens that he said had started to wear. The result: That eye was now blind and growing increasingly painful.
The ophthalmologist, another specialist told her later, had implanted the lens in the wrong position, obscuring her sight and puncturing a duct, causing a slow bleed and massive pressure.
“There was so much blood in there, it blew the eyeball out of my head. It was hanging on my cheek,” said Church, a razor-sharp 83-year-old. “I was hysterical, the pain was so bad.”
Both incidents point to dangerous breakdowns in the Canadian health-care system. But don’t expect to find any public record of either apparent blunder — or of thousands of similarly harmful and sometimes deadly mistakes that occur in facilities across the country each year.
Most instances of the system hurting rather than healing patients, in fact, are not even reported by staff internally, a National Post investigation has documented.
Research suggests that about 70,000 patients a year experience preventable, serious injury as a result of treatments. More shocking, a landmark study published a decade ago estimated that as many as 23,000 Canadian adults die annually because of preventable “adverse events” in acute-care hospitals alone. The rate of errors may be even higher today, some evidence suggests, despite the millions of dollars spent on much-touted patientsafety efforts.
Yet a tiny fraction of those cases are publicly acknowledged and usually only in the form of antiseptic statistics. For most serious treatment gaffes, not even the sparsest of details is revealed, making the vast problem all but invisible.
“Learnings from these things, even when a good investigation is done, are going into black holes,” said Darrell Horn, a “criticalincident” investigator who spent several years with the Winnipeg Region Health Authority. “They’ve created this perfect, invisible box to put everything in.”
Manitoba is actually a rare exception to the opaqueness that shrouds medical error in Canada; single-line descriptions the province has released for the last three years offer at least a snapshot of what calamities can befall patients. Among the 100 cases reported in the three months ending Sept. 30, 2013, was that of a new mother who had a heart attack after staff inadvertently gave her a blood-pressure-increasing medication, instead of a nausea antidote following a caesarean section.
Another patient, known to be at risk for blood clots, suffered a fatal cardiac arrest when staff neglected to provide preventive treatment after surgery.
A woman needed a second operation after an X-ray revealed a screw from a broken clamp had been left inside her during a C-section.
And, without further explanation, one patient “underwent unnecessary open-lung biopsy.”
For the rest of the country, such cases occur in a vacuum, most not reported at all and virtually none described with any kind of narrative.
In fact, legislation in most provinces bars information on adverse events being released to malpractice plaintiffs or publicly divulged under freedom-of-information acts. The laws are designed — with limited success — to encourage internal reporting of mistakes.
A health-care culture still straitjacketed by an oldfashioned hierarchy, fear of legal action and a focus on punishment rather than learning from mistakes also keeps missteps bottled up, say health workers and safety experts.
A nurse at an Ontario hospital, who asked not to be identified for fear of repercussions, said she works with two surgeons whose skills are so lacking, “I wouldn’t even want them to touch my dog.”
She filed an anonymous complaint against one several years ago, but little changed. Now, she stays mum about problems ranging from high rates of post-op infections to surgeries frequently needing re-dos.
“We do turn a blind eye and walk away,” the nurse admitted. “There is a lot of lying, there’s a lot of coverup, which turns my stomach.”
By contrast, preventable injury and deaths in many other arenas are routinely divulged by police or other authorities. The starkest counterpoint to health care’s lack of transparency around error is offered by the aviation industry.
On the way to dramatically improving the safety of flying, the sector has become conspicuously open about its mishaps. Canada’s Transportation Safety Board, for instance, posts details online of current investigations into everything from actual crashes to ground vehicles inadvertently driving across airport runways.
The constant, transparent exchange of safety information not only helps curb accidents, but enhances passengers’ confidence in the industry, says John Pottinger, an aviation-safety consultant and former Transport Canada official.
The point of publicizing medical error, patient-safety experts stress, is not to shame or blame, or take away from the fact health care is replete with highly trained, dedicated professionals.
When things do go wrong, it is typically the result of a complex interplay of factors, often involving underlying flaws in the system. Finding ways to prevent those mistakes is, of course, the ultimate goal and subject of intense research and numerous initiatives.
But publicity about error helps both in drawing attention to the issue and providing a well of knowledge, say safety experts.
“You have to tell people that patients are getting hurt,” said Rob Robson, a physician who led the Winnipeg health authority’s groundbreaking patient safety program for seven years. “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.’ ”
In reality, no one knows exactly how prevalent medical error is in Canada. The best approximation comes from a widely accepted 2004 study spearheaded by the University of Toronto’s Ross Baker and University of Calgary’s Peter Norton, now known simply as Baker-Norton.
The researchers examined patient charts at a representative sampling of 20 acutecare hospitals. They found that 7.5 per cent of adult patients — which extrapolates to 185,000 a year countrywide — suffered a serious adverse event, almost 40 per cent of which were preventable. Between 9,000 and 23,000 people die annually from preventable error, they concluded.
Eight years later, a similar study looked at pediatric patients, finding the rate at which children are hurt by adverse events was even higher, 9.2 per cent. And, if anything, the numbers may have climbed since, says Hugh MacLeod, chief executive of the federally funded Canadian Patient Safety Institute.
“With the pace, the increase of new technology, new drugs, new approaches ... the probability of risk and incident has grown,” he said.
Monique Chisholm considers her son Cullan’s disabilities to be a product of one of those tens of thousands of medical slip-ups.
When she checked into hospital in Antigonish, N.S., four years ago, her thoughts were predictably upbeat, but in the ensuing hours a fetal-heart monitor showed “clear evidence” the baby was suffering hypoxia, a dangerous shortage of oxygen, alleges a malpractice suit the mother later filed.
Yet the nurses, overseen by a senior obstetric specialist-in-training, continued to administer pitocin, a drug designed to induce labour.
Cullan ultimately was delivered using vacuum extraction, revealing that the umbilical cord was wrapped around his neck, the statement of claim says, leaving him “seriously compromised” and, it later became clear, severely brain damaged.The doctor responded in a statement of defence that it was only just before delivery the fetal monitor indicated an abnormally slow heart rate, and she performed generally in a “prudent, skilful and competent” manner.
Regardless, Cullan lives today with one of the most severe forms of cerebral palsy. And yet, few errors of the sort Chisholm alleges are reported in facilities, shared across jurisdictions or actually publicized.
Four provinces — Alberta, New Brunswick, Newfoundland and Prince Edward Island — release no data on adverse events at all.
With some fanfare this year, Chisholm’s Nova Scotia became the latest jurisdiction to divulge criticalincident data. But the total number of incidents for the first six months of 2014 was a mere 27. John McKiggan, a Halifax malpractice lawyer, says even some of his doctor friends laughed at the figure, suggesting it should be more like 27 a day.
Meanwhile, Church, a retired consumer-relations executive at American Express, now has a prosthesis instead of her right eye, curtailing an active life that had included four rounds of golf a week.
And the pain that led to the ovarian-cyst diagnosis, which was never treated, still keeps her up at night.
“My life is entirely turned around,” she said.
“I think it’s abominable that these people can do this, and there is no repercussion. ... I think people should know (about medical error) and people should ask, people should question.”