The Untimely Death of Madeleine Mendoza: A Husband’s Journey from Medical Tragedy to Patient Safety, Part II
A retired business systems analyst, Ed Mendoza recalls tackling his share of complex problems throughout his working career. Little did he know that one day he would be forced to question the logic of one of the largest systems in our country – Canadian health care.
The untimely death of his wife Madeleine in March 2003 raised many questions about the quality of patient care and the accountability of health care providers within the Canadian health care system. Ed knew that he must do something to prevent others from experiencing similar medical tragedies. In 2004 he cashed in some retirement savings and created an information booklet containing Madeleine’s story and a poll to find out about the health care experiences of other Ottawa residents.
Two weeks prior to the mail out of his booklet, the results of “The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada” appeared in the May 25, 2004, issue of the Canadian Medical Association Journal. News of the study inspired Ed to pursue his health care poll and in early June the information was sent out to more than 250,000 homes in Ottawa. People soon began relaying their experiences with Canadian health care. Wishing to share this valuable information, Ed contacted the funding partners for the adverse events study. Both the Canadian Institute for Health Information (CIHI) and the Canadian Institutes of Health Research (CIHR) recommended contacting a new national agency called the Canadian Patient Safety Institute (CPSI). In November 2004 he met with the Director of Operations for CPSI and provided her with a summary of his poll results. He never heard from her again.
Patient Safety Groups
A year later, Ed discovered that the Winnipeg Regional Health Authority (WRHA) in Manitoba was collaborating with patients and their families to improve patient care and safety. He contacted their Chief Patient Safety Officer and asked if he could work with their organization. In May 2006 Ed travelled to Winnipeg and attended a meeting of the WRHA’s Patient Safety Advisory Council at which time he became an official satellite member of the group. He provided them with all of the data from his poll and collaborated with them to produce a presentation and poster outlining lessons learned from patient experiences in the health care system. The WRHA promoted Ed’s work by featuring him in their newsletter and on their website. Hoping to broaden the reach for delivering his message on patient safety, Ed also became a Patients for Patient Safety Champion through the World Health Organization’s World Alliance for Patient Safety and joined a newly formed patient group called Patients for Patient Safety Canada (PFPSC). His membership in these groups enabled him to participate in a few national patient safety conferences.
In February 2008 he sat on the steering committee of PFPSC and helped them develop a charter for the organization. Three months later the amicable relationship between Ed and the WRHA ended abruptly when they informed him that a restructuring of their Patient Advisory Council meant that he could no longer be a member. Ed was extremely disappointed but undeterred in his patient safety efforts. In September 2008 the CPSI, the funding body for PFPSC, invited him to speak at their Canadian Patient Safety Officer Course. One month later he received a call from PFPSC dismissing him from the group. In January 2009 he received an official letter outlining the reason for his expulsion. The letter makes reference to his speaking engagement and the message contained in his information booklet.
The Journey Continues
Ed’s journey from medical tragedy to patient safety resembles that of a roller coaster ride with many inclines and declines. Sometimes he is given opportunities to participate in the patient safety movement where his message is embraced and he feels like he is contributing to changes in our health care system. Other times his message is considered controversial and the opportunities for it to be heard quickly disappear. His experiences with government-funded patient safety groups have lead Ed to believe that many of them do not wish to address the performance issues of health care providers.
“Everything is blamed on the system like it’s some inanimate object,” he says, “but systems don’t run themselves. Every system has a human component.”
Ed is now revisiting his plans for starting an organization dedicated to improving the accountability of health care providers and the quality of patient care in the Canadian health care system.
“My life’s goal is to see evidence of just one person having survived a medical tragedy as a result of something I contributed to,” says Ed.
You can contact Ed Mendoza by email at firstname.lastname@example.org