Coming clean on medical mistakes

Tanya Talaga
Robert Cribb
Staff reporters
http://www.thestar.com

When a 44-year-old Edmonton mother of three died from an accidental overdose of a chemotherapy drug last August, Alberta health officials admitted the mistake and issued a public apology.

That public admission sparked changes in Toronto. The University Health Network immediately reviewed their procedures on dispensing chemo at Princess Margaret Hospital to prevent the same mistake from happening inside their walls.

It’s practical evidence of what a growing number of medical professionals now believe: Honesty is the best policy when it comes to medical errors and patient safety.

As many as 23,750 people die each year from in-hospital adverse events, according to statistics from the Canadian Institute for Health Information.

“That’s more than the number of people who die from breast cancer, motor vehicle and other transport accidents, and HIV combined,” according to a 2004 report from the data agency. But few medical mistakes ever garner any public attention.

The key reason doctors and hospitals are close-mouthed about mistakes is the fear of medical malpractice lawsuits. It’s a widespread risk management strategy that is both morally questionable and misguided, says Dr. Steve Kraman, a professor of medicine at the University of Kentucky and author of a study titled “Extreme Honesty May Be the Best Policy.”

In 1987, Kraman, who was then a longtime chief of staff at the Veterans Affairs Medical Center in Lexington, Ky., implemented a policy in which hospital officials came clean about mistakes. Instead of opening up a flood of lawsuits, the policy produced surprising financial benefits, says Kraman.

“People don’t sue for the money by and large. Studies show over and over that people just want to find out what happened. It’s surprising how charitable people get when they know they’re being told the truth and given information they know they deserve. At that point, it becomes about something other than money.”

While the hospital still offered and paid compensation to those who suffered from medical errors, those payments averaged about $16,000 (U.S.) – rather than the costs of court settlements or judgments that could run as high as $500,000 (U.S.) – and were generally completed in a matter of months rather than years.

“It’s a proper thing to do, it benefits everybody in the long run and it’s affordable,” says Kraman. “There’s nothing magical about it other than just remembering what your grandmother taught you.”

There’s no public record about what happened to a pregnant Erin Goodchild, whose baby died 13 hours after she was hospitalized at Lakeridge Health’s Port Perry site for abdominal pain and vomiting on April 21, 2005. The baby, named Emily Joyce, was stillborn at 27 weeks after the placenta – the organ babies rely on for all nutrients and oxygen – dislodged from the uterus.

Investigations by the College of Physicians and Surgeons and the Office of the Chief Coroner concluded there were problems with Goodchild’s treatment. Both agreed the baby would have had a better chance of survival had her mother been transferred to Women’s College Hospital sooner.

In the end, the complaints committee called physician Dr. James Tuck in to personally caution him about “the care and management of potential abruption in pregnancies with placenta previa,” according to a report obtained by the Star.

It intended to ask him to review relevant literature and “come prepared to discuss with the committee the management of abdominal pain in pregnancy.”

Prospective patients, however, will find no mention of the college’s concerns on its website, though they will benefit from a policy change at Lakeridge prompted by Emily’s death.

From now on, anyone less than 30 weeks pregnant with complaints will be considered to have obstetrical complications and be transferred to a hospital that handles high-risk patients.

Tuck did not respond to requests for an interview.

Brian Lemon, CEO of Lakeridge Health, wouldn’t speak about Goodchild’s case specifically, but did confirm the hospital reviewed obstetrical care in light of the Goodchild case and implemented recommendations made by the coroner.

If more honesty were policy, patients would be less likely to sue, says Dr. Alex Levin, staff ophthalmologist at the Hospital for Sick Children. “I can’t tell you every doctor in this country practises disclosure when they should. That’s why there is continued, ongoing educational efforts to improve disclosure, to encourage disclosure, to teach doctors how to disclose better.”

When a patient feels they’ve been the victim of a medical error or systemic errors, the onus is on them to complain. That process can seem insurmountable to someone who is ill or devastated by loss.

Many patients shy away from suing doctors, hospitals or other health providers because the costs are prohibitive.

Doctors have deep pockets. They pay malpractice insurance premiums to the Canadian Medical Protective Association, a group that defends doctors against legal actions, which has more than $2 billion in defence fund reserves.

The number of lawsuits is dropping against doctors at an average of 5 per cent each year, according to the CMPA.

Adverse events – hospital parlance for medical errors – are collected and reported via the Ontario Hospital Association’s annual report card. Largely an administrative tool, the report card isn’t meant for consumption by the average patient. Adverse events are listed but they are not easily defined: Pressure ulcers and patient falls in hospital are but two of a long list lumped under one category. If a patient is lucky, they’ll wind up in a hospital that keeps track of medical errors and near misses.

At the University Health Network, one of Canada’s largest hospital corporations, comprising Toronto Western, Toronto General and Princess Margaret, the chief executive officer reviews all adverse events. In 2006, it will likely report around 4,000 of these at three sites, says Dr. Robert Bell.

“You might say that is terrible,” says Bell. “But those might be near misses and they frequently are. What we want to provide to our staff is the feeling they are responsible.”

The UHN has a policy that says every staff member – from doctors on down – is responsible for reporting adverse events. An electronic Web-based system keeps track. Every time one of those adverse events occurs, an email flashes up on the CEO’s desk. “Once a month we review those adverse events and we talk about what have we learned from each one of those.”

Near misses can be a nurse saying she almost gave a patient the wrong drug because two pills look the same and they are kept close together in the same drawer.

“Rarely an adverse event leads to a patient death,” he said. “It’s more of increasing patient discomfort.”

The consensus from most in the health field is to make it all public. But don’t mention names.

“People are all human. Everybody can make errors, even doctors,” said Lemon at Lakeridge Health.

Two years ago, the United States passed the Patient Safety and Quality Improvement Act, which allows doctors to report errors anonymously. It means hospitals will scrutinize critical incidents and report and share findings among other healthcare providers. The act was prompted in part by an Institute of Medicine study that estimated as many as 98,000 people in U.S. hospitals die annually because of preventable mistakes.

So far, health systems in at least 24 states have adopted blame-free medical error reporting, an idea borrowed from the way the airline industry handles near misses in the air.

Pilots report mistakes anonymously and the whole system benefits, argues Phil Hassen, head of the Canadian Patient Safety Institute, a federal group formed by the provincial health ministers in 2003 as a not-for-profit organization to promote a safer healthcare system.

“The airline industry 20 years ago said they’d reduce by 80 per cent the deaths in airlines. That was their goal. And they’ve achieved that because of the reporting system,” says Hassen. Every error is treated like a learning opportunity. You can report anything and you won’t be held personally liable for it if you report it right away.”

The Canadian response has been to set up Safer Healthcare Now!, a campaign that involves 151 hospitals and health-care systems. They are trying to reduce adverse events in six areas: surgical and central line infections, pneumonia complications from breathing machines, adverse drug reactions, heart attacks and rapid response teams that can save lives anywhere in the hospital. The Health Council of Canada is floating the idea of introducing no-fault medical insurance in Canada. In a no-fault system, compensation is provided in response to the event – it doesn’t matter who or what caused it.

“The issue in Canada is, in order for a claim to be laid against a health-care provider who causes harm, the courts have to demonstrate there was intent to cause harm,” says Jeanne Besner, interim chair of the council. “Most of the adverse events that occur in the healthcare system are not the wilful intention of the healthcare providers.”

The Ontario Hospital Association wants to see a provincial patient safety institute established here.

“We really need to do so much more,” says Hilary Short, OHA president.

“One of the challenges is the instant sharing of adverse events,” says Short. “If something happens in Wallaceburg, we need to know in every single hospital in the province what happened.”

Nearly two years after the death of her baby, Goodchild frequently checks the college’s website to see if her case is mentioned. But it never is.
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