Monday, October 24th, 2016

Blowing the Whistle on Patient Safety: Why Patients Need to Speak Out


whistleblowerPatient safety is a hot topic in Canada and one that often leaves our politicians scrambling to maintain some semblance of action. They do so by creating more federal, provincial and territorial agencies and programs. Many of these government-funded initiatives are set-up as independent (arm’s length) non-profit organizations. Perhaps the biggest endeavour to date is the creation of the Canadian Patient Safety Institute (CPSI).

Established in 2003 this national organization receives $8 million annually to fulfill their mission “To provide national leadership in building and advancing a safer Canadian health care system” Their stated vision includes a Canadian health care system “Where patients, providers, governments and others work together to build and advance a safer health care system…” but their voting members include only national medical and health care organizations and federal, provincial and territorial health agencies. As a patient, I question how effective this organization can be in building a safer health care system without actively engaging the patient voice. I suppose they have found a partial answer in supporting the formation of Patients for Patient Safety Canada. This group “Works in collaboration with the Canadian Patient Safety Institute and World Health Organization World Alliance for Patient Safety to make “Every Patient Safe”.

It would be interesting to hear the response of the CPSI to the latest examples in our health care system outlining why individual patients must continue to speak out on matters of patient safety.

In December 2009 the Provincial Auditor for Saskatchewan, Fred Wendel, released his findings from an August 2009 audit of the Regina Qu’Appelle Regional Health Authority’s processes for patient safety. The audit included a review of adverse events related to surgical complications, medications and falls. The findings indicate that the regional health authority had “adequate processes in place for patient safety in its health care facilities except for analyzing patient safety reports to learn from its experience.”  Wendel’s report contains three recommendations. The first one is improving communications to staff regarding the highest risks to patient safety, contributing factors and recommended actions. The second one is the analysis of contributing factors to direct appropriate courses of action. The third recommendation is an annual report on patient safety results including targets, outstanding concerns and possible solutions.

If you think it’s better in other provinces and territories- think again. Many questions are now being asked following the December 2009 release of a report containing recommendations for improving patient safety in the Vancouver Island Health Authority (VIHA). An analysis of 491 incident reports from the West Coast General Hospital in Port Alberni, British Columbia revealed that changes made to their incident reporting form and database could provide immediate results for patient safety. Changes to the form include identifying the types of incidents occurring, the contributing factors, and improving the management and employee feedback necessary for a successful incident reporting system. Modifications to their electronic database would allow the VIHA to aggregate data thereby making it more useful for identifying areas for systemic change. The two long-term recommendations include moving from a paper-based form to an electronic web-based reporting system for better data collection and quality and providing sufficient resources to the Quality and Patient Safety Office to study the data and implement necessary changes.

You would think these improvements would be made as quickly as possible but that is not the case. In a recent news article a VIHA spokesperson referred to the report as “frickin’ gobbledygook” and “redundant” in light of VIHA implementing a new provincial patient safety learning system in 2010. The report is understandable and its recommendations make sense to those who would like to see change occur. However, changes in the VIHA may be a long time coming as the position of Heather Shon, Leader of Patient Safety, has been dissolved along with the Office of Quality and Patient Safety. As public servants both Shon and the report’s author Brian Vatne are prohibited from commenting publicly.

These examples serve as reminders that the safety of patients in the Canadian health care system remains questionable, highlighting the need for patients to continue to demand transparency and accountability regarding issues of patient safety and to keep speaking out.

Update – In March 2010 the Canadian Patient Safety Institute (CPSI) officially announced the appointment of Hugh MacLeod as its new CEO. Later that year the CPSI changed its vision, mission and adopted Safer Healthcare Now! as its flagship program.

Federal funding for the CPSI is set to expire in March 2013. By that time the agency will be ten years old with a taxpayer price tag of around $90 million. How much safer is our health care system? Let’s ask the patients who use it.


3 Responses to “Blowing the Whistle on Patient Safety: Why Patients Need to Speak Out”
  1. Carol says:

    I was in the hospital (VIHA) during my stay I was retrained and shackled not once but twice. The more I thought about it I realized how wrong and illegal it is. Can you provide any literature and policies and procedure on this subject. You cabn contact me in Victoria by phone (250)298-0656, or email conleysargeant@shaw,ca. Thank you

  2. francais says:

    I recently went to West Coast General port alberni with horrific stomach pains, pain moving in band around my lower back and into my right thigh. I had since been to Nanaimo General on four seprate emerg visits-with blood work only done the first vist. The second visit I was asked to pee in a cup, and did so-only to be questioned weeks later by my G.P. why I was drug screened? =I had no idea they had done that screen, I was not informed or notified. THe third nrgh visit I had new doctor who gave me CT scan and they found a mass-was given more morphine and sent home. The fourth nrgh emerg visit the nurse asked, “What is your drug of choice?- isn’t that why you’re here, with ‘pain’” She actually did the hand gesture for quotation marks as she asked me that question. I was given morphine in my arm and discharged-so waited in parking lot alone STILL in pain and drove myself home. After my fourth nrgh vist it was suggested I go to another hospital if things get worse=they did….bands of pain, sweats, bodily movements NOT moving for four days now and the pains are crippling ( I am an otherwise healthy 39year old very active woman)……so I went to Port Alberni-a 40minute drive in opposite direction, in pain, but at least hopeful………..only to get to emerg window where a CLERK said,’ Well, really, they found a mass, so, what do you really think we are going to do here? I mean, if they didnt’ do bloodwork or tests there why would we? I mean…, why are you here??” I sat, flabbergasted, on verge of tears, and then Very Very angry………. I asked to see a doctor…she again said, ‘why, I mean, …..why?’ so i ripped off my bracelet and left in tears ….and STILL in pain…….

    where is the health CARE in health care??????????????????????????????????????????

  3. Marianne says:

    I am working on knowledge exchange for a study funded by the Canadian Patient Safety Institute looking at safety issues at home. I am not working directly for CPSI and my post does not represent the views of CPSI or my organization. I just wanted your community to know that we are looking into patient perspectives through articles and websites such as this one. I personally feel compelled to let you know that this story, along with other patient stories, are interesting, inspiring, important and informative. Keep up the good work! These perspectives have contributed to helping us form key messages from our research to patients, care givers, and decision makers to improve patient safety. We hope our results can be distributed to the community through websites such as this one.

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