Report details medical error horrors
Adverse events have led to 1.1 million added days in hospital per year, researchers say
By ANDRÉ PICARD
PUBLIC HEALTH REPORTER
Thursday, June 10, 2004 - Page A21
Source: The Globe and Mail
Treating people who fall prey to medical errors gobbles up more than 1.1 million hospital days and adds a whopping $750-million to the country's health-care bill each year, a new study suggests.
The news follows on the heels of a groundbreaking study revealing that one in every 13 medical/surgical, acute-care hospital patients suffers from an "adverse event," and that these failings, avoidable and otherwise, kill up to 24,000 Canadians annually.
The new report, released yesterday by the Canadian Institute for Health Information, provides graphic details on the woes befalling patients.
The data show that: one in nine adults contracts an infection while in hospital, ranging from pneumonia to SARS; one in nine patients receives the wrong medication, or the wrong dose; one in 20 women suffers severe tearing during childbirth; one in every 81 babies born vaginally suffers trauma, emerging with injuries such as a broken shoulder; one in every 299 patients receiving a blood transfusion will have a reaction; one in every 1,124 adults over the age of 65 suffers a broken hip during a hospital stay; one in every 6,667 surgery patients will have a foreign object left in his or her body after the procedure.
"Like nuclear energy and aerospace, health care is a complex environment where errors can maim and even kill," said Jennifer Zelmer, vice-president of research and analysis at CIHI. She said about one-third of adverse events are preventable.
While the vast majority of patients recover quickly, Ms. Zelmer said the additional resources required to deal with medical errors is substantial. Patients who suffer harm often have their hospital stays prolonged. While unable to provide a detailed cost breakdown, she said a conservative estimate of the cost of 1.1 million hospital days of care would be about $750-million.
Adverse events are unintended injuries or complications caused by health-care management, not by the underlying disease.
Sav Rosenberg, 61, of Laval, Que., knows all too well the cost. On Feb. 26, he was admitted to Jewish General Hospital for a routine prostate operation but, just before discharge, he contracted a bacterial infection, Clostridium difficile.
"I was supposed to stay, originally, for three days. I ended up 24 days in the hospital and I'm still sick," Mr. Rosenberg said. He has only recently been able to return to work, driving a cab. Still, he was a lucky one; at least 79 patients have died of the virulent infection in recent months.
Mr. Rosenberg said he had "no idea" he could get sick in hospital.
John Wade, chairman of the new Canadian Patient Safety Institute, said this anecdote demonstrates there is a lot of work to be done in improving both patient safety and patient education.
"This report provides us with valuable information on the incidence and magnitude of adverse events. Now it's time for action," he said.
But Dr. Wade, an anesthesiologist, cautioned that patients have to be realistic. "We're aiming for zero, but we will never get to zero; we will never eliminate error or adverse events completely."
He also said the numbers have to be kept in perspective. There are about 2.5 million admissions to acute care hospitals in Canada annually. About 187,000 patients suffer from adverse events. Of that number, between 9,250 and 23,750 died in 2000 after a failure in their treatment. (This does not imply that the medical error was directly responsible for their death, because many hospital patients are already acutely ill.)
Michael Decter, chairman of the Health Council of Canada, said that reducing the number of adverse events must be a priority because it undermines faith in the health system, and adds substantial costs.
He also suggested that the Canadian public is too tolerant of failings in the health system. "Were we in any other industry, facing a problem of this magnitude, I suspect there would be enormous public consternation," Mr. Decter said.
But he was quick to add that the solution is to give health professionals the tools to improve care, not persecute them when things go wrong, often inadvertently.
"This is a massive problem that's going to have to be dealt with by thoughtful effort, not by blaming people," he said. Mr. Decter said one approach that should be seriously considered is no-fault insurance for patients who suffer from adverse events.
The new research on adverse events was just one element of the fifth annual report of the Canadian Institute for Health Information. The CIHI is an independent, not-for-profit organization mandated to improve the health of Canadians and the health-care system by providing quality health information.
Frequency of complications in hospital
There are roughly 2.2 million patients discharged from hospital a year in Canada. A national estimate of the average number of Canadians who receive care or are exposed to a risk per adverse event:
1 in 9 adults with health problems reported being given the wrong medication or dosage by a doctor, hospital or pharmacist in the past two years.
1 in 16 reported an adverse event for themselves or a loved one in the past year.
1 in 152 deaths are associated with preventable adverse events for medical/surgical patients in acute care hospitals.
1 in 1,124 people over age 65 suffered in-hospital hip fractures.
1 in 6,667 had a foreign object left in their body after a surgical procedure.
1 in 72,046 got infected with hepatitis B from a blood transfusion.
1 in 10 million got infected with HIV from a blood transfusion.
SOURCE: CANADIAN INSTITUTE FOR HEALTH INFORMATION