Patient Safety

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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  • Jon thank you for your extensive comment

    Bill B

    Bill | August 31, 2013

  • Our hospital system is an absolute mess. I say this as a person who has be hospitalized for six heart attacks over the past 25 years and has spent a fairly considerable time as a part time resident in the hospital.

    First, highly trained staff are underused. Nurses should be with patients, but if you go to any acute care ward, you will see them handwriting patient charts in the nursing stations which look more like offices than a nursing delivery centre. A computerized system is needed that takes advantage of technology most frequently used by teenagers so that nurses can actually spend time nursing instead of being clerks.

    Second, the doctors are all specialists and seldom see past the professional blinders imposed on them by their specialty. None of them seem able to see past the borders of their specialty. Common sense is often missing. I had a roommate who spent his first night in agonizing pain. When the doctors made their round and he complained of the pain he suffered from the doctors asked him a few questions and concluded that in addition to his heart problems, he was suffering from gout. They sent for a rheumatologist. The man’s problem was that he had fainted before he came into the hospital and fell on a sidewalk. He landed on his knee and broke his kneecap. They were not particularly happy with my suggestion that they should X-ray his knee and treat the break. But that solved the man’s problem. If there had been a few GPs on staff, a more common sense approach to treating patient’s problems might prevail because GPs are used to treating the whole patient.

    Third, our hospitals are filthy. This leads to outbreaks of infections. If you are admitted to one of our hospitals today, you will have to submit swabs from your mouth and your groin area to be cultured to see if you are bringing in an infection. A more common sense approach would be to have enough cleaning staff to actually scrub our wards within an inch of their lives. Lister proved that clean wards led to better patient outcomes. Some penny pinching bureaucrat has decided to outsource cleaning and to pay so little that you cannot afford to place your bare feet on the floor because they will acquire a coat of dirt on your feet.

    Fourth, the food services are run by dieticians. There may be a dietician somewhere who knows how to cook, but the quality of food in the hospitals are bad enough that patients don’t eat much of it. In my last 10 day stay I lost 15 pounds. Why not hire real chefs who know how to cater to large numbers of people? A dietician can tell you about the chemical values of the food they dispense, but if it tastes like s__t, it won’t get eaten.

    Fifth, the entire process is set up to run from 9:00 to 5:00 – five days per week. If it’s a long weekend, then the hapless patient is doomed to spend three extra days without any active treatment of his condition. Only extreme emergencies get treated. All those expensive machines sit idle because there is no staff to operate anything but a skeleton operation.

    Sixth, our hospitals are basically a make-work project. There more clerks than are needed. The next time you go to a hospital I invite you to just look around and see how many idle people you can see. It would be better to reclassify the clerks and make them into cleaners – at least they would be doing something useful.

    Seventh, the doctors have forgotten basic rules of hygiene. The last time I was in the QE-II, I noticed that the room next to mine was an isolation ward. The cardiologist assigned to me would leave this room and enter mine. I had to remind him to wash his hands before he examined me. Again, Mr. Lister would have rapped him on his knuckles if he were still alive.

    Eight, we have scores of administrators earning more than $100,000 per year. Why? What possible administrative function in a hospital is worth more than $100,000? We also have scores of lawyers on retainer in the Capital Health District.

    Ninth, we have waiting lists because we don’t have enough facilities to clear them up. We need specialty hospitals – why not one hospital in the Capital District which does nothing but orthopedic work until the years long backlog is eliminated. If the hospitals can’t do this, allow someone in the private sector to open a clinic and bill the Health Department?

    Finally, we have 10 district health authorities with their attendant high priced help. Why do we need this top-heavy level of administration? We are a province of 850,000 people. We are organized as if we had a population of 8-million people. Why? Probably because Medicare is a sacred cow which we simply throw money at. What we need is a thorough housecleaning with the intent of putting medicine and the patients first. But, since both levels of government have squandered funding on this system for years, the system has become self-perpetuating. It is like a drug addict with no greater concern than to grow its demand for more funding. Given this sort of organization, is it any wonder that an unfortunate woman was misdiagnosed and had her healthy breasts removed?

    Jon Coates | August 31, 2013

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