Admitting errors reduces them: Montreal hospital
Province to use Jewish General as model for creating registry of incidents
Last Updated: Saturday, November 7, 2009 | 10:47 PM ET
CBC News
Montreal's Jewish General Hospital has reported a 50-per-cent drop in the number of adverse incidents in the past three years. (Courtesy of Colin Rose)Montreal's Jewish General Hospital says a full-disclosure policy regarding mistakes made during patient care is responsible for a 50 per cent drop in adverse incidents over the past three years.
The hospital’s policy is being lauded by provincial health-care officials, who are using it as a model while they work toward the creation of a provincewide registry of incidents.
So far this year, the hospital has reported just three serious mistakes compared to seven in 2006.
Hospital employees are told anyone can make a mistake but what is important is reporting one when it happens and learning from the incident, said Dr. Joseph Portnoy, the hospital’s co-director of risk management.
"Our professionals, our employees are working in an environment where they know they should report near misses," Portnoy said. "I made a mistake — let's see what this can do to make this safer for our patients. We do this all the time, and we are very proud of it."
Bernie Weinstein became a patient advocate at the Jewish General eight years ago after his own mother-in-law was the victim of a medication mix-up.
At the time, Weinstein said it took a formal complaint to the hospital’s ombudsman to get anyone to admit something had gone wrong.
"And to be told — 'Don't worry; it's okay' — it's not the answer," Weinstein said. "What you really want to hear is, 'We know what went wrong, and we are doing something. And we apologize. It won't happen again because we're going to do something to ensure it doesn't'."
Now Weinstein says the hospital actively solicits patient feedback. 
Hospital staff are encouraged to admit their mistakes and learn from them, says Dr. Joseph Portnoy, the hospital's co-director of risk management. (CBC)
The hospital receives about 5,000 complaints a year, officials said.
Portnoy cites a more recent example in which a patient had been hooked up with the wrong tube — one carrying air instead of fluids.
The same mistake had happened elsewhere — with fatal consequences.
But Portnoy said nothing was done about it until an employee at the Jewish General reported what had happened there.
"The [manufacturing] company was forced to change their model [of tubing]," Portnoy said. "Now, they have a tubing of a different size. So even if they want to connect [the incorrect tube] … you can't connect it."
The Health Ministry said it hopes to have its registry of adverse incidents ready by April.
