Flying blind in the face of error

Medical errors are as old as medicine itself. So why is it that even now serious slip-ups in the health profession are usually met with the tacit assumption that they should never have happened? There will always be mistakes we can't prepare for. It boils down to the fact that medicine is not a precise science and humans are fallible. That's not to say we shouldn't strive to improve the healthcare system and set up fail-safe mechanisms to catch as many potential disasters before it's too late.

So how bad is the problem? Unfortunately, error is mostly a hidden epidemic, so it's tough to gauge exactly how many accidents happen. Owning up to a mistake is difficult at the best of times but medicine's tradition of fingerpointing can stop even the most conscientious doc from coming clean. Often the errors we do hear about are the ones that result in serious injury or death. However, disclosure of the mistakes that usually get swept under the rug -- the near misses and close calls -- are just as important. This crucial piece of the puzzle can give us a more complete picture of Canadian healthcare and, more importantly, reveal the cracks in the system.

To gain full cooperation, sensitive and fair treatment of health professionals who report errors -- whistleblowers included -- is imperative. This will require a much more sympathetic approach from administrators than we've seen in the past. A computerized system could very well pave the way for preventing prescription mix-ups, while better training and wider use of protocols would minimize diagnostic errors.

To achieve this goal, we could take a page out of the airline industry's book. They spend much more time and money on training and put more effort into accurate reporting of errors as opposed to assigning blame. A change of attitude in the medical profession will definitely go farther toward fostering an open system of disclosure than the threat of disciplinary action. The recent CMAJ report on adverse events (see our cover story Klutz like a knife) goes some way toward enlightening us about how far gone the situation really is, but we need to be far more diligent. This insidious problem can no longer go unchecked -- quality control is nothing less than an essential service in healthcare. We need to get a handle on the situation now before it spirals out of control.
-- Shereen Joseph, Editor

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