June 9, 2004

Medical mistakes clogging system

By HELEN BRANSWELL

TORONTO (CP) - Patients who have experienced medical errors are
clogging up a huge number of hospital beds every year in Canada,
potentially absorbing as many available beds as all women going
through pregnancy and childbirth, a new report suggested Wednesday.

As many as 1.1 million hospital days may be attributable to
correcting problems caused by so-called adverse events, the Canadian
Institute for Health Information said in its annual report. In
addition to endangering the lives and health of people, adverse
events are draining badly needed resources from the overtaxed system,
said Dr. John Wade, the chair of the Canadian Patient Safety
Institute.

"I think there's a huge economic argument to be made that that's
costing the system billions of dollars and that if we could prevent
some of that, rather than patient safety (initiatives) costing the
system, it should save the system," Wade said in an interview.

"And those monies could be reinvested in (reducing) wait lists or
whatever."

The number of hospital days was calculated using data taken from a
recently released landmark study which sought to establish for the
first time the rate at which things go wrong in hospitals and what
impact that has on the patients.

That study, by Prof. Ross Baker of the University of Toronto and Dr.
Peter Norton of the University of Calgary, found that one in 13
people experienced an adverse event while in hospital and that the
medical error added on average six days to their hospital stay. The
CIHI report extrapolated that to reach the 1.1 million hospital days
figure.

The Baker-Norton report also found that preventable errors may be
contributing to between 9,200 and 24,000 deaths a year - a range the
experts at Wednesday's report release admitted they found surprising.

"No matter how you slice it, it's a very high number. And it's one
that causes great concern and . . . it's urgent to attack it," Wade
said.

Michael Decter, who was chair of the institute of health information
when it agreed to co-fund the Baker-Norton study, said he'd initially
hoped it would show the long-accepted estimate of 10,000 preventable
deaths was an exaggeration.

"So this is a massive problem which is only going to be dealt with by
very thoughtful effort. Not by blaming people but by finding a way of
bringing the errors out into the open so that we can find better ways
of doing things," Decter said.

The institute helped shed more light on the scale of the problem by
analysing some of its own data, gathered from hospitals across the
country, as well as the released Baker-Norton data and information
from other sources.

Its analysis suggests:

- One in nine adults contract an infection while in an acute care
hospital. The number among children is one in 11. Urinary tract
infections, surgery site infections and pneumonia are the most common
of these.

- One in 20 women experience third or fourth degree tears during
childbirth.

- Birth trauma occurs in one in every 81 births. Trauma can range
from a dislocated shoulder to much more serious problems.

- One in 1,100 seniors break a hip by falling while in hospital.

- One in 6,700 people who have surgery have a foreign object, things
like a sponge or a surgical instrument, left in them during surgery.

Some measures are being adopted in efforts to reduce medical errors.
Some hospitals, for instance, require a surgeon to sign a patient's
body in a pre-surgical visit so they'll be sure to cut in the right
spot when the patient reaches the operating room.

And studies have shown that electronic record keeping - using
computer programs designed to flag potentially dangerous drug
interactions - can reduce the rate of medication errors. But
electronic records have not been widely adopted as yet.

Still, experts believe a culture shift needs to occur in hospitals
before major progress can be made. Surveys suggest health-care
professionals are aware of the problem, but feel pressure to hide
mistakes because they fear being sued.

Norton said members of the public have to have the right to sue if
they sustain serious harm from medical errors. But the system needs
some adjustment to ensure that health professionals can openly
address the problem so that they can seek solutions.

"In some sense we need to have a correction, a steering correction,"
he said from Calgary.

Wade agreed, noting the patient safety institute believes provincial
evidence laws should be changed to allow medical workers to discuss
errors in a "privileged" environment where their comments could not
be used against them later in court. The institute is drafting a
template for that legislative change, he said.

That doesn't mean hospitals should be able to hide errors, he
insisted. Most provincial regulatory bodies require errors to be
noted on patient charts and discussed with patients and their
families.

There's an advantage to hospitals in that, Decter noted. Studies
suggest people who have been told they were the victim of an error
are less likely to sue than those who were not told.

Until medical professionals feel free to reveal and discuss errors,
the goal of improving patient safety will remain elusive, Wade said.

"If we don't change the culture from one of blame and shame to one of
information sharing and solving the problems, we won't make much
headway."

SOURCE: WEB PAGE http://cnews.canoe.ca/CNEWS/Canada/2004/06/09/pf-
492284.html

Claudio Acuña
claudioacuna@...