Posted August 30, 2013
Sharon Fisher had an unnecessary mastectomy and other patients received the wrong treatment. Ms. Fisher was understandably upset and her faith in the system shaken. In fact, mistakes in the health care system are not uncommon.
A 2004 article in the Canadian Medical Association Journal studied Adverse Events (AEs). AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. The study estimated close to 70,000 potentially preventable AE’s in a year.
Improving safety is an important issue not only for health but also for workplaces, driving, and aviation. The best programs are transparent and relentless, but not event driven. Perhaps the most effective program in the world is the international effort to improve commercial airline safety. It is 60 times safer to travel a kilometer in an airplane than it is in a car.
It was not always so. Every accident in commercial aviation is thoroughly studied to understand the causes and prevent recurrences, but that is not the primary reason for the steadily improving safety record. Rather, it is a comprehensive system for reporting near misses and close calls. This much larger database identifies risks from equipment malfunction, operator error, or poorly designed procedures. Those who report problems can have their anonymity protected but the information provided is made widely available and carefully studied. The result has been continuous improvement in an already impressive safety record.
Well-run businesses follow a similar protocol. While lost time accidents are thoroughly examined, the biggest source of learnings is near-miss reports. Smart business leaders count it as a success if the number of such reports goes up. It means that employees are constantly thinking about safety issues and identifying opportunities for improvement.
The health care system has been slow to develop an appropriate risk reduction strategy. Until recently there was no coordinated recording of medical errors, let alone near misses. The medical establishment has not always been comfortable acknowledging fallibility. In the past several years, Capital Health and the other health authorities have begun collecting data on both incidents and near misses and providing data to the Department of Health.
Capital Health numbers for last year were almost 20,000, of which more than 97% are near miss, no harm or minimal harm. Health Minister Wilson had this to say about the error that affected Sharon Fisher, “Patient safety is very important to me and when I did hear about this, I felt sick to my stomach.” He acknowledged that the department would now begin to aggregate and share the data received from the different authorities, something that should have begun long ago.
He also asserted that the “mistake doesn’t reflect any shortcomings with the authority’s budget.” How would he know, given the disinterest his department has shown in incident reporting?
Progressive Conservative leader Jamie Baillie had no comment at all on the topic. The prize for over-the-top reaction goes to Liberal health critic Leo Glavine, “Recent reports of tragic and troubling medical procedure errors are cause for great concern… Patients and families deserve comfort that horrific medical errors such as those recently reported will never happen again.”
That isn’t going to happen. Nor will huffing and puffing by politicians eliminate traffic accidents or workplace fatalities. To pretend that there will be no Adverse Events in the health system is to lie to Nova Scotians.
The goal is to minimize the risk. The way to do so is by transparent reporting and well considered responses to incidents when they occur.
For that, and for grace under pressure, the prize goes to Capital Health CEO Chris Power. She was fully and sincerely apologetic to the affected patients. They and the Minister were informed early. Ms. Power acknowledged that there were both systemic and human errors. She said that Capital Health’s focus would not be to punish but rather to document and learn from the mistake. And in response to the Minister’s assertion that budget was not the issue she had this carefully non-committal response, “Our staffing levels were no different than they had been at, you know, at other different times.”
In trying to deal with this year’s budget pressures, Capital Health proposed outsourcing some food operations which would save $1.4 million per year. Perhaps if this proposal had not been rejected there would have been more money to prevent errors like Sharon Fisher’s unnecessary mastectomy. More broadly, politicians and voters need to understand that improvements to patient safety occur in many small steps. What is needed is an active, relentless, and transparent process. This is the best hope for reducing the number of errors like the one that Ms. Fisher was so unfortunate to experience.
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