The World Forum - June 22nd, 2024

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Inside Canada's secret world of medical error: 'There is a lot of lying, there’s a lot of cover-up'

Research suggests that about 70,000 patients a year experience preventable, serious injury as a result of treatments. More shocking, a landmark study published a decade ago estimated that as many as 23,000 Canadian adults die annually because of preventable “adverse events” in acute-care hospitals alone.

The rate of errors may be even higher today, some evidence suggests, despite the millions of dollars spent on much-touted patient-safety efforts.

Yet a tiny fraction of those cases are publicly acknowledged and usually only in the form of antiseptic statistics. For most serious treatment gaffes, not even the sparsest of details is revealed, making the vast problem all but invisible.

The Post has also learned there is no routine, public documentation of one common source of health-care harm — malfunctioning medical devices linked to dozens of deaths and hundreds of serious injuries every year.

Manitoba is actually a rare exception to the opaqueness that shrouds medical error in Canada; single-line descriptions the province has released for the last three years offer at least a snapshot of what calamities can befall patients.

Among the 100 cases reported in the three months ending Sept. 30, 2013, was that of a new mother who had a heart attack after staff inadvertently gave her a blood-pressure-increasing medication, instead of a nausea antidote following a caesarean section.

Another patient, known to be at risk for blood clots, suffered a fatal cardiac arrest when staff neglected to provide preventive treatment after surgery.

A woman needed a second operation after an X-ray revealed a screw from a broken clamp had been left inside her during a C-section.

And, without further explanation, one patient “underwent unnecessary open-lung biopsy.”

For the rest of the country, such cases occur in a vacuum, most not reported at all and virtually none described with any kind of narrative.

In fact, legislation in most provinces bars information on adverse events being released to malpractice plaintiffs or publicly divulged under freedom-of-information acts. The laws are designed — with limited success — to encourage internal reporting of mistakes.

A health-care culture still straitjacketed by an old-fashioned hierarchy, fear of legal action and a focus on punishment rather than learning from mistakes also keeps missteps bottled up, say health workers and safety experts.

A nurse at an Ontario hospital, who asked not to be identified for fear of repercussions, said she works with two surgeons whose skills are so lacking, “I wouldn’t even want them to touch my dog.”

She filed an anonymous complaint against one several years ago, but little changed. Now, she stays mum about problems ranging from high rates of post-op infections to surgeries frequently needing re-dos.

“We do turn a blind eye and walk away,” the nurse admitted. “There is a lot of lying, there’s a lot of cover-up, which turns my stomach.”

By contrast, preventable injury and deaths in many other arenas — from homicides to industrial accidents and road crashes — are routinely divulged by police or other authorities.

The point of publicizing medical error, patient-safety experts stress, is not to shame or blame, or take away from the fact health care is replete with highly trained, dedicated professionals. Aside from a tiny smattering of true incompetents, no one comes to work expecting to dispense anything but exemplary care, says Rob Robson, a physician who led the Winnipeg health authority’s groundbreaking patient safety program for seven years.

When things do go wrong, it is typically the result of a complex interplay of factors, often involving underlying flaws in the system, he added. Finding ways to prevent those mistakes is, of course, the ultimate goal and subject of intense research and numerous initiatives.

But publicity about error helps both in drawing attention to the issue and providing a well of knowledge, say safety experts.

“You have to tell people that patients are getting hurt,” said Dr. Robson. “As long as the public doesn’t realize that one in 13 people coming into the hospital will experience some kind of adverse event — and that’s the conservative estimate — then there isn’t any pressure to say, ‘Listen, fix these damn things.’ ”

The risk inherent in hiding such information was tragically highlighted in 1997, when yet another child fell victim to a classic medical error,  an error some believe still occurs.

Doctors at the B.C. Children’s Hospital administered a series of drugs to Kristine Walker, a seven-year-old whose leukemia had come back. Inadvertently, they injected vincristine — meant for intravenous use — into her spinal fluid. Doctors have known since the late 1960s that using the medication “intrathecally” triggers catastrophic, usually fatal neurological damage.

Kristine became paralyzed and died two weeks later. After her death, the hospital discovered that at least three similar incidents had occurred in other provinces in previous years, reminders of the importance of preventive measures. None were made public or even communicated within the health-care system.

In reality, no one knows exactly how prevalent medical error is in Canada. The best approximation comes from a widely accepted 2004 study spearheaded by the University of Toronto’s Ross Baker and University of Calgary’s Peter Norton, now known simply as Baker-Norton.