Health care quality

Unearthing Medical Errors for Learning Opportunities

February 1, 2016

Unexpected tragedies, such as a plane crash, create particular resonance with people. The aftermath of such salient events leads to in-depth investigations and frequent reports by the media. No stone is left unturned until there is a complete, full understanding of what went wrong, and how it can be prevented in the future. Far less attention and energy is focused on the estimated 23,000 deaths that occur annually in Canada from medical errors in hospitals alone1, which begs the question, if this much effort and resources go into investigating the deaths of a few hundred people on a plane, why aren’t equivalent or greater measures taken to report, investigate, and prevent medical errors that result in preventable deaths?

Admitting we have a problem

One issue surrounding medical errors in Canadian and American health care is the lack of accountability and transparency on part of health care providers and systems. Understandably so, as an antiquated culture of hierarchy and secrecy has left many clinicians and health care workers with a fear of retribution, and to a higher extent, legal action, if they were to disclose their mistakes2. However, this fear of the “blame game”, and lack of disclosure paralyzes researchers’ and authorities’ ability to investigate the extent of the problem and determine effective solutions.

Death rates due to preventable medical errors are estimated to actually be closer to 35,000 annually, rather than 23,000 previously mentioned. Most surveys only account for acute care, excluding long-term care, obstetric, and psychiatric care facilities. Hospital-acquired infections alone account for approximately 8,000 to 12,000 deaths a year3.

The first major challenge is an absence of data. Manitoba is leading all Canadian provinces in data collection for medical errors over the last three years—single line descriptions of serious injuries and events. A leading example when compared to Alberta, New Brunswick, Newfoundland, and Prince Edward Island, which release no adverse event data, in comparison. Also, despite a Global Alert Program initiated by the Patient Safety Institute to help alleviate reporting deficiencies, only two Canadian institutions actually utilize the service1. A greater investment in data capture and reporting will be necessary to overcome this first challenge.

Learning from each other

Another challenge is getting the medical sector to become more open at communicating their failures for shared problem solving and quality improvement. According to John Pottinger, a former Transport Canada official and aviation-safety consultant, a “constant exchange of safety information not only helps curb accidents, but enhances passengers’ confidence in the industry”, when discussing the dramatic levels of transparency and incident reporting exhibited by the aviation industry. Everything from near-misses, minor incident reports, to major crash investigations are posted online for public viewing by Canada’s Transportation Safety Board1. Safety experts echo this, stating that keeping patients in the dark will only heighten their concerns and suspicions of malpractice.

One fatal incident in 1997 involving a young leukemia patient at BC Children’s Hospital highlights the need for cooperation and transparency around medical errors. Then President, Lynda Cranston, stated, “We were not able to learn from our own mistakes, nor did we have the opportunity to learn from those of our colleagues”, upon learning that similar, preventable errors, resulting in paralysis and death after a spinal vincristine injection, had occurred at other Canadian hospitals in previous years.

Preventing medical errors requires team effort

Changing the perception around medical errors is critical to reducing them. A study investigating media coverage surrounding medical errors pertaining to cancer care found that the majority of news stories placed the responsibility, or blame, on individual clinicians, rather than framing it as an institutional or health sector issue4. This only reinforces the fear around transparent and open communication; responsibility for errors should be shared collectively by all stakeholders, providers, policy makers and patients.

Dr. Rob Robson, the physician who led Winnipeg’s patient safety program, states that “with the pace of increase of new technology, new drugs, and new approaches…the probability of risk and incident has grown”; this further necessitates better communication and teamwork to prevent potential mistakes. As in the aviation industry, adopting checklists has proven to help reduce errors by standardizing workflows and promoting greater communication between team members. Studies found that communication failures commonly occur in the operating room, but with the implementation of customized Surgical Safety Checklist (SSC), developed by the World Health Organization, miscommunication declined by 50%5, which has been highly correlated with increased teamwork, and lower frequency of errors during an operation6, 7.

Shifting the culture in health care from fear of blame or punishment to one that fosters collaboration and collectively embraces an improvement mindset and tools to reduce medical errors is the key to safer patient care.

Notes

  1. Blackwell, T. (2015, January 16) National Post. Inside Canada’s secret world of medical error: ‘There is a lot of lying, there’s a lot of cover-up’. Retrieved from http://news.nationalpost.com/news/canada/inside-canadas-secret-world-of-medical-errors-there-is-a-lot-of-lying-theres-a-lot-of-cover-up
  2. Levinson, W., Gallagher, T. (2007) Canadian Medical Association Journal. Disclosing Medical Errors to Patients: A Status Report. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1930188/
  3. Finlay, K. (2015) Huffington Post. Preventable Medical Error is Canadian Healthcare’s Silent Killer. Retrieved from http://www.huffingtonpost.ca/kathleen-finlay/medical-error-deaths_b_8350324.html
  4. Li, J., Morway, L., Velasquez, A., Weingart, S., Stuver, S. (2015, March) Journal of Patient Safety. Perceptions of Medical Error in Cancer Care. Retrieved from http://journals.lww.com/journalpatientsafety/Abstract/2015/03000/Perceptions_of_Medical_Errors_in_Cancer_Care___An.7.aspx
  5. Henrickson SE, Wadhera RK, Elbardissi AW, Wiegmann DA, Sundt TM. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg 2009; 208 (June (6)):1115-1123
  6. D.L. Davenport, W.G. Henderson, C.L. Mosca, S.F. Khuri, R.M. Mentzer Jr.
    Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg, 205 (December (6)) (2007), pp. 778–784
  7. K. Catchpole, A. Mishra, A. Handa, P. McCulloch. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg, 247 (April (4)) (2008), pp. 699–706
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