Speaking out about medical errors that cost lives

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First aired on The Current (17/04/13)

The number of people who die each year in Canada as a result of medical error is estimated to be in the tens of thousands. Among the most notorious cases is that of Lisa Shore, a 10-year-old girl who died at the Hospital for Sick Children in Toronto in 1998. Her case is one of those profiled in a new book, After the Error: Speaking Out About Patient Safety to Save Lives by Susan McIver and Robin Wyndham. Co-author Susan McIver, who also wrote a previous book on the subject of medical errors, dropped by The Current to talk about some of the cases covered in the new book.

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When asked why she published this new book on the subject, Mciver told guest host Matt Galloway that she felt it was necessary because "the errors are still continuing." The numbers are staggering: 24,000 deaths a year in Canada are due to medical error. "That number is for deaths in acute-care hospitals alone," McIver pointed out. If other clinical settings like walk-in clinics and long-term care facilities are taken into account, "the estimate for the total number of deaths in our health care system is 40,000."

After the Error tells the stories of individuals who have suffered as a result of medical error. In doing her research, McIver found herself disturbed by "the difficulty that many of the contributors had in getting the problem recognized by health care professionals, not just individuals but groups such as health authorities and hospital authorities."

One of the cases documented is that of 77-year-old Esther Winckler, who went into the Chilliwack, B.C., hospital for hip surgery and died 15 days later as a result of a series of medical errors. The Current spoke to her daughter, Catherine Winckler, who described what happened in the days after the surgery. Her mother was moved to different wards, and eventually ended up in a general ward where she was not properly monitored and fell twice from her hospital bed, suffering a brain injury as a result.

After Catherine Winckler pressured the authorities for an investigation, there was a coroner's inquest, which gave a detailed summary of errors, including a lack of care by doctors and nurses, little pain management and no diagnosis of falls. "At every point along that way, there were so many opportunities to have a different outcome," Winckler said.

According to McIver, the errors that ended up costing Esther Winckler her life could still happen now. "Athough there is increasing attention being paid, there are still errors, there's still resistance to change."

The Current also spoke to Dr. Chris Hicks, an emergency room physician at St. Michael's Hospital in Toronto who has done research into how to prevent errors. "Mistakes happen because medicine is run by people, and people always make mistakes."

McIver agreed, but suggested that "we can all learn to do things better." She mentioned two current initiatives that are helpful: an emphasis on hand hygiene and an effort to reduce errors in medication. She also said that some hospitals have started to implement "the use of a checklist, and that is that whatever procedure is happening, there's a checklist [with] all the things that have to be done."

Another story in After the Error is about Heidi Klompas, whose legs were broken when she was hit by a car. Her surgeon delayed operating, and she died as a result of complications. "If she had had surgery more promptly, the outcome would have been different," McIver said. A Vancouver Sun investigation found that the surgeon had been the subject of a number of complaints, and the College of Physicians and Surgeons had asked him not to practice until receiving psychotherapy. McIver believes that the College should take away the licences of physicians who are not up to standard. She cited a study done in the U.S., which found that "approximately two per cent of the physicians account for something like 20 per cent of the errors."

In hospitals, there tends to be a culture of erecting a wall of silence around errors, but McIver said that things are changing. "This is one of the good things about the movement for patient safety...people [in authority] are beginning to realize the importance of paying attention to communication."

McIver's advice to someone who's a patient, or has a loved one going into hospital? "Keep a record of what medications are given, what doctors are seen, what nurses are seen, what tests are required, and the results of those tests," she said."To work with health care professionals but also to be aware that...those professionals are also human, and they may make mistakes."




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