Klutz like a knife

Canadian study blows the lid off adverse events in hospitals

By Peter Woodford

What do theme parks and medicine have in common? Both share a shocking lack of data on adverse events. In the medical community, reticence in reporting error has given us, at best, a murky etiology of error. But a recent Canadian study could help change all that and uncover the true extent of this hidden epidemic.

A widely anticipated study conducted jointly by the Canadian Institute for Health Information (CIHI) and the Canadian Institutes of Health Research on adverse events in Canadian hospitals was published in the May 25 issue of the Canadian Medical Association Journal (CMAJ). The study found a 7.5% rate of adverse events in hospitals across the country. Of these, the authors conclude that 36.9% were preventable. According to the study results, adverse events occur most often during surgical procedures; next in line was drug or fluid administration.

A review of the severity of the adverse events in the study showed that 35.6% of patients escaped the flubs relatively unscathed, 5.2% were left with permanent disabilities while an unfortunate 15.9% died. All told, 64% of adverse event sufferers were either only slightly harmed or not harmed at all.

IT'S ABOUT TIME
Many in the Canadian healthcare field have long been clamouring for such a study. In a public statement, Dr Ken Milne, director of Patient Safety and executive vice-president of the Society of Obstetricians and Gynaecologist of Canada lauded the work headed by Drs G Ross Baker and Peter G Norton, proclaiming that "a major barrier in addressing patient safety issues is a lack of acknowledgement that the problem actually exists at all. The patient safety report should accomplish this." He added that "one of the recognized barriers to reducing clinical risk or error and increasing patient safety has been a long-standing culture of blame, of pointing fingers."

HEART OF THE MATTER
Dr David Alter, a cardiologist at the Schulich Heart Centre of Sunnybrook and Women's College Health Sciences Centre in Toronto, and an assistant professor of Medicine at the University of Toronto, has also been anxiously awaiting the results of the study. He feels it's an important step in the grand scheme of improving accountability in the Canadian healthcare system. It's time to make a distinction between system-wide errors, such as overzealous fluid administration guidelines, and rare but existing errors caused by staff negligence. For the latter, he thinks individual discipline is appropriate, but for system errors he's happy with Sunnybrook's protocol. Group meetings are called and staff are given the opportunity to share learning experiences about adverse events, near misses and unusual cases where standard diagnoses have failed to find the real causes of patients' illnesses. "These meetings can be quite constructive," says Dr Alter. "We have these meetings not infrequently at all." He also calls attention to fact that there's often a silver lining in the dark cloud of an adverse event. "There's nothing like an error or a near miss to alert a physician to a problem."

INTERNATIONAL VIEW
Similar studies have been conducted in other countries. Canada's rate of adverse events is lower than New South Wales/Southern Australia's (10.6%) and New Zealand's (12.9%). However, we don't stack up quite as well as the US, according to a similarly study done there back in 1992. There are several ways to interpret this finding. For one thing, it's possible that because the US study had a medico-legal focus -- rather than the quality improvement perspective of the Canadian study -- the numbers may be skewed. One benefit of the ambulance chaser' culture in the US, however, is that it forces more diligent record keeping. In any case, any comparison between the two studies must be taken with a grain of salt, as the methods used to gather information weren't identical.

A landmark article entitled "Is US health really the best in the world?" published in 2000 in the Journal of the American Medical Association really sparked the current interest in adverse events. The article's findings shocked many as it revealed that iatrogenic mortality was the third leading cause of death in the US after heart disease and cancer. It's important to clarify, however, that this study found that almost half of these deaths were not caused by negligence per se but adverse reaction to drugs that were correctly administered based on current guidelines.

To put the whole thing in perspective, the CMAJ study found that there was one fatal, preventable adverse event in every 152 hospital acute care surgeries. Meanwhile, an earlier study published last year in the CMAJ found that a relatively common patient fear -- contracting HIV from a blood transfusion -- only occurs in just one of 10 million cases. According to CIHI data there's one foreign object left in a patient's body for every 6,667 surgical procedures. That's still pretty rare, but perhaps less so than you might have thought.

"It may seem a strange principle to enunciate as the first requirement in a hospital that it should do the sick no harm," observed Florence Nightingale. "It is quite necessary nevertheless to lay down such a principle." This study clearly reinforces that sentiment.