Four-year-old Courtney Braund, a recovering leukemia patient in a Halifax hospital, was set to receive her last chemotherapy treatment.
On this particular April day in 1992, she was also scheduled to receive dental surgery due to side effects from the treatment. Her usual chemotherapy drug, vincristine, was a potent medication that is deadly if injected into the spinal cord.
That night, Courtney was very restless while sleeping in her parents bed. She screamed and vomited the next morning, prompting her parents to take her back to the hospital. Although the error was identified immediately, nothing could be done to change the outcome. Courtney died a week later.
This case, outlined in Healthcare Papers – New Models of the New Healthcare, outline the series of events which led to the error occurring. This included Courtney being treated in a different unit than usual leading to the vincristine being administered in the same room as drugs that were to be injected into the spinal cord. As well, Courtney’s regular doctor was unavailable, and the doctor who did treat her was distracted by the news that one of his other patients was on route to the hospital in critical condition, leading to a failure to notice the drug warning label. As well, no operating room staff scrutinized the doctor’s actions.
Health care errors are surprisingly common. According to a paper written by Certified Health Educator, Laura MacDermaid, 7.5 per cent of hospital admissions resulted in adverse events in 2000. This meant that approximately 185,000 out of 2.5 million hospital admissions in Canada had adverse results, and over 36 per cent were determined to have been potentially preventable. She used a Canadian Medical Association Journal study as the basis for these arguments in her award-winning 2005 paper presented to the Canadian College of Health Leaders.
While not all of these adverse events cause death or even injury, they all carry the potential to do so. This trend is by no means confined to Canada, though. The aforementioned study estimated that in the US, medical errors claim the lives of up to 98,000 Americans each year, costing the US health system up to $29 billion annually. This is therefore an issue that all health care systems in developed countries should address.
While the exact cost to the Canadian health care system has not been accurately estimated, it is significant based on the number of reported errors. In fact, according to Dr. Anne Matlow, a University of Toronto professor in the Department of Pediatrics, a single blood infection due to an error can cost the health care system $35,000 to treat.
In order to reduce the number of errors, a number of initiatives should be put in place. I recently attended a talk by Dr. Bob Bell, the CEO of the University Health Network, in which he mentioned that a culture of safety needs to be fostered in hospitals. According to Dr. Bell, this can be achieved through a cultural shift involving the “flattening” of hierarchies, meaning, all health care providers – including nurses and other staff – should feel comfortable pointing out errors to physicians in high risk situations. As well, University Health Network hospitals now use checklists in all operating rooms that confirm the patient is the correct one, and that the surgery will be done on the right body part, in order to minimize potential mistakes.
Furthermore, on a recent tour of the Toronto General Hospital Emergency Department, I observed a collaborative board on which staff wrote down suggestions on ways to reduce wait times and meet efficiency goals, which were reviewed and implemented by the hospital’s management. This type of board, adapted to patient safety, could be used by all staff to write down suggestions on how to reduce medical errors. The key is for these proposals to be blameless to encourage people to come forward in identifying unsafe situations that could result in an error. This allows operations to be modified to reduce the probability that an unlikely sequence of events will lead to an error being made.
In addition, the implementation of complete Electronic Medical Records facilitated by eHealth Ontario and Canada Health Infoway will allow all levels of the health care system to view patients’ complete medical histories. In terms of information technology, the Ontario health care system has not been as progressive as other industries, partly due to the independent nature of each provider. This has resulted in health care providers operating in silos, largely relying on patients’ own recollections of their medical history, which increases the probability of errors when emergency treatment is required. Therefore, in order to prevent medical errors, all health service providers should strive to integrate these systems before the 2015 deadline outlined in the eHealth Ontario 2015 Blueprint.
Although there have been many processes put in place to reduce the possibility of human error, such as the installation in operating rooms of different shaped couplings for oxygen and nitrous oxide outlets to prevent the accidental administering of anaesthesia instead of oxygen, more can be done.
Cultural shifts in health care settings to support a safety-focused environment requires a commitment by the Ministry of Health and Long Term Care to focus on creating best practices for the health care system to reduce errors. While it is easy to blame health care staff when errors do occur, it is more constructive to use a blameless model in which errors act as a starting point for discussions on prevention.
Matt Warwick is a second-year Master of Public Policy student at the University of Toronto with an interest in health care. Upon graduation, Matt is hoping to help create policies which enhance the quality of health care.