Canada wasn’t the first country to examine the rate of adverse events in its hospitals, but it did learn a thing or two from those already on the road to patient safety. From the outset of the Canadian Adverse Events Study, its funding bodies and researchers worked with health care stakeholders to enable them to prepare responses and launch various safety initiatives and projects. By the time the study results were published in 2004, the federal and provincial governments, professional, regulatory, and health care organizations had already established a direction for patient safety.

Much of their efforts focused on gathering more and better hospital data by encouraging and promoting a ‘culture of no blame’ among health care providers. Based on the premise that most medical errors are caused by system failures, it forgoes placing individual blame in favour of reporting and sharing information on adverse events. It operates on the belief that without such a culture errors will go unreported and system improvements left unmade. The lack of individual responsibility and accountability within this ‘culture of no blame’ meant that some patients did not embrace it as readily as other health care stakeholders.

Over the years, public demands for greater accountability in health care have led a number of provinces to enact legislation for reporting, disclosing and apologizing for adverse events. However, variations in legislation coupled with differing definitions and hospital policies can lead to selective reporting and disclosure. Even more discouraging to patients and their families is the legal protection afforded to information obtained through quality reviews and investigations. Many medical errors still go unreported and are only brought to light by patients filing formal complaints or approaching the media. In many of these cases there is even a tendency to try and shift blame towards the patient.

Now the patient safety movement is embracing a new ‘just culture’ proposing to combine the systemic error approach of a blameless culture with some individual accountability tied to reckless behaviour.

Do these cultures reduce the incidence of medical errors or do they merely result in blame-shifting and therefore liability-shifting between health care providers and the systems in which they work?

What happens when individual accountability is not addressed? Some of the more highly publicized cases involving patient harm include Ontario gynaecologists Dr. Errol Wai-Ping and Dr. Richard Austin, both of whom were allowed to continue practicing despite a number of formal complaints filed against them over a period of years. Hundreds of women came forward with their stories following a series of investigative reports by The Toronto Star.

What happens when system failures are not addressed? A letter written by Dr. Paul Parks of the Alberta Medical Association to the provincial Minister of Health recently appeared in the Calgary Herald. It expresses concern over the ongoing system failures causing a crisis in emergency medicine in Alberta. The letter reveals prior communications regarding system failures and compromised patient care dating back to 2008. It also contains a grim prediction “Again, our data and feedback from Emergency Physicians throughout the province indicate that our overcrowding problem continues to worsen and we anticipate the potential catastrophic collapse of timely emergency care delivery in the upcoming months. There must be an intervention immediately.”

Preventable adverse events are driving us down the road to patient safety. How far have we come? From a patient perspective, I believe we are halfway between nowhere and somewhere. It’s time to take a new direction and it’s up to us, as patients, to help lead the way.

There is good news for patients around the world scheduled to have surgery on May 5, 2010. You may experience a reduced risk for hospital-acquired infections thanks to the observance of a world hand hygiene day. The World Health Organization (WHO) leads this global campaign promoting the importance of hand hygiene within the health care setting.

On this day, health care providers in participating facilities around the globe will be reminded of when and how to wash their hands based on the WHO’s “My 5 Moments for Hand Hygiene” approach and its official guidelines.

Here in Canada, the day is being celebrated as Stop! Clean Your Hands Day and our health care providers will take note of “Your 4 Moments for Hand Hygiene” approach adapted from the original standard.

Participating Canadian health care organizations and facilities have access to a variety of tools for monitoring compliance to the program including various checklists to be completed by health care providers. For those short on time, a condensed “on the spot” version of the checklist is available. Registrants will also receive new report cards developed by the Canadian Patient Safety Institute (CPSI) for patients and their family members to record their observations of hand hygiene practices. These cards include paid postage for mailing the results back to the CPSI who will then provide this feedback to the participating organizations. Alternatively, if the health care facility supports “Ask. Listen. Talk.” then feel free to just tell them your results. A helpful handout is available on one of the CPSI’s websites outlining how to best address the issue of hand hygiene with your health care providers. Patients and their family members should also be prepared to answer questions about their own hand hygiene practices within the health care setting.

Undoubtedly, good hand hygiene practices in the health care environment can lead to reduced rates of hospital-acquired infections. However, a health care environment in which process infects and overwhelms common sense poses a much greater danger to both patients and providers.

Stories highlighting patient safety problems in the Canadian health care system appear in daily news reports across our country. The list includes misdiagnosis, drug, lab and surgical errors, dirty hands and dirty instruments, medical charting errors and omissions, unsupervised medical residents, and poor care management.

More hospitals are now using checklists in pre-surgery, post-surgery and intensive care units to help reduce the number of medical errors. These checklists contain a number of items outlining some of the minimal standards for patient care and can be modified to suit the needs of each hospital.

Many argue that checklists are needed for health care providers working in busy hospital environments dealing with complex medical conditions and care. With increasing health care budget deficits and funding cuts to hospitals across Canada, the only real cost for implementing checklists is the time required from health care providers to complete them. It is an easy sell in the name of patient safety but, in truth, the usefulness of checklists is limited.

Medical mistakes may soon be attributed to the failure to include certain items on one of these many lists. This very situation was recently alluded to by the Ontario Minister of Health Deb Matthews following two cases involving a doctor performing unnecessary mastectomies on patients. In an article appearing in the February 24 edition of The Windsor Star, Matthews makes reference to a checklist containing an item that would have prevented these errors from occurring. However, the article also reveals that the hospital where these surgeries were performed already uses a type of verbal check prior to surgery. In light of these cases, another hospital in Windsor is already making changes to its checklist implemented in January.

While checklists may be a helpful tool for encouraging communication and teamwork they cannot ensure provider competence. The ultimate patient safety check resides in the professional and personal performance of each doctor and health care provider using their knowledge, skills and judgement in delivering high quality patient care.

Until we start addressing the lack of transparency and accountability in our health care system and the deeper issues associated with this, the true changes required from both providers and hospitals for driving patient safety remain unchecked.

Patient 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.

You don’t have to be a brain surgeon to know that a man who has undergone brain surgery needs to remain in hospital for more than two days. Especially if he is already considered to be a high-risk patient due to pre-existing conditions including blindness and heart problems.

The Health Sciences Centre in Winnipeg, Manitoba tried to discharge Monty Vann two days after the surgery for removing his brain tumor. Vann, not feeling well enough to be released, fought to remain in hospital for another three days. Only five days after his brain surgery he finally agreed to the hospital’s wish to discharge him. While on his way home Vann suffered a stroke. He is now in hospital where he remains unresponsive.

I am sorry to hear about yet another case in which there will likely be no accountability for the events. I’ve talked about the search for accountability in our health care system in a previous post. Vann’s case is not unique but rather commonplace in our Canadian health care system. Things will only begin to change when the patient voice is heard.

Are you ready to have your say?

Accountability?

According to the Canadian Adverse Events Study (2004), an estimated 185,000 hospital admissions are associated with adverse events each year resulting in the deaths of 24,000 Canadians annually. Around 70,000 of these adverse events are deemed to be preventable.

You’ve gone to the hospital for emergency medical treatment or surgery. You suffer an adverse event that leaves you with grievous injuries.  How will you find out what really happened? Who is accountable? Who will help you?

Patients are often encouraged to discuss their complaints concerning a hospital with a Quality Care Coordinator or Client Representative usually found at the regional or provincial/territorial level. Formal complaints against a doctor can be made to the College of Physicians and Surgeons within a province/territory. A patient may also wish to consult with legal counsel to file a medical malpractice claim. All of these complaint mechanisms are limited by various factors.

Most, if not all, client representatives are employees of the provincial/territorial government and must meet the needs of their employer. Many of the case reviews performed by professional self-regulating bodies often result in educational recommendations to their members. Anyone who has considered filing a legal claim soon discovers that most doctors are members of the Canadian Medical Protective Association (CMPA). The CMPA is a non-profit organization whose mandate is to promote the professional integrity of doctors and safer medical care in Canada. The legal and financial resources that the CMPA is able to offer each of its members is unmatched. In 2008, their assets were estimated to be $2.43 billion.

Victims of medical malpractice quickly learn that their legal options are limited by the severity of their injuries and their financial resources. It takes a number of years for a case to proceed through the courts and if the decision is in favour of the defendant doctor then you must also pay for their legal fees. Your injuries must be severe enough to insure that the amount of compensation being sought will cover your legal and medical bills. An interesting fact to note is that many provincial/territorial governments subsidize the fees doctors’ pay to belong to the CMPA which means that your own tax dollars are being used to fund the defendant’s case against you.

The CMPA’s 2008 Annual Report indicates that 884 legal cases commenced in Canada last year with only 88 of these proceeding to trial where only 13 judgements were found in favour of the (patient) plaintiff. There were 574 cases abandoned or dismissed and 341 settled.

What does all of this mean for you as a patient? If you experience an adverse event in one of our hospitals you will enter yet another labyrinth of government bureaucracy where you will eventually tire from your search for accountability. Along the way you will hear talk about “mandatory reporting”, “disclosure” and “apology” legislation and policies and will find excuses but no answers. You will have trouble finding a lawyer to represent you due to the legal and financial resources required for a medical malpractice claim. If you succeed in finding legal representation then be prepared to dedicate several years and at least $100,000 towards your legal claim and, depending on the courts, you may still end up without any compensation. These are some of the realities facing patients in our Canadian health care system.

Information on accountability in our health care system is scarce. The Canadian Policy Research Networks (CPRN), a social policy think tank, has  published a series of papers under the research area titled “Strengthening Accountability in the Canadian Health Care System”. The complexity of our system and its lack of accountability to the public are evident throughout the series. The CPRN was to prepare a final report that would provide specific recommendations for our health care system. This report, to date, is incomplete.

Pictured above is the stack of letters I’ve received during my search for accountability.  Where do you find accountability in the Canadian health care system?

Please let me know.