In Depth
Health
Hospital safety
Experts prescribe an ounce of prevention
Last Updated April 17, 2007
By Georgie Binks
When 84-year-old Frances Marie Tanner broke her leg in December 2001, doctors figured she would recover without any problem. But when a nurse at Peterborough Regional Health Centre in eastern Ontario mistook a vial of potassium chloride for a saline solution and injected it into Tanner's IV, she died almost immediately.
Tanner is among thousands of Canadians who have died as a result of a preventable medical error. In 2004, the Canadian Adverse Events Study found preventable medical errors caused between 9,000 and 24,000 deaths in Canada a year. Those errors included health-care providers giving patients the wrong or too much medication, operating on the wrong limb, leaving a sponge in a patient, injuring a baby during delivery and patients contracting an infection after surgery.
After that study, written by Dr. Ross Baker, a University of Toronto professor in health, policy and management, an initiative began in spring 2005 called Safer Healthcare Now. Aimed at improving patient safety in Canadian health-care facilities, it involves 600 teams of health professionals in more than 180 hospitals and health regions across Canada.
Baker said results of the campaign's first phase show patient safety has improved, but there's still work to be done.
Changes to health system needed
"If you want to improve patient safety, you have to improve what happens in the front lines of patient care," he said. "You have to engage doctors and nurses to look at what you know will lead to safe care. It's a tough time in health care – they're already very busy, so we have to give them very explicit directions about what to do."
Take, for instance, medication errors like the one that took the life of Tanner. Baker said, "The majority of patients who enter the hospital don't have an accurate recording of their medications put into the hospital charts so we make sure they're on the right medications in hospital. Medications are missed that should be continued, others are started that may conflict with existing medications."
He added that many patient-care units are now considering adding staff to interview patients to get that information. He said the long-term answer is bar-coding every medication coming out of the pharmacy, then scanning a bar code on a patient's wristband.
David U, head of the Institute for Safe Medication Practices, said patients can take steps to help protect themselves, too. "Nurses should be following a certain protocol, identifying the patient and the medication, but patients, their families and caregivers need to ask questions about medications."
Tanner's son John said his mother's death has affected the way he takes care of himself in the hospital. He always makes sure he is given the correct medication, and recently, when he took his own child to the hospital, "I didn't leave him alone for a minute."
Avoiding nasty bugs
Hospital infections are another huge problem.
Toronto lawyer Michael Birley, 57, is an example – he underwent a routine arthroscopic procedure on his knee in October 2001, but ended up with a staphylococcus aureus, a "hospital bug," which spread through his body. Birley was given intravenous antibiotics and missed three months of work.
The cost to patients and the health-care system from preventable medical errors such as this one is enormous. In Quebec in 2005, for instance, preventable surgical site infections cost hospitals more than $10 million. Baker said one way to reduce these types of infections is to give patients antibiotics an hour before their surgeries and discontinue them 24 hours later. However, he said, the problem is figuring out who will be responsible for it and do it consistently.
Sunnybrook Health Sciences Center in Toronto has achieved a 35 per cent reduction in surgical site infections in its cardiac surgery unit. Baker said, "If you reduce a reasonable number of these infections, we estimate you can free up as many as 20 to 30 beds in a medium-sized hospital on an ongoing basis. That would help a lot of people who can't get into hospital because there aren't enough beds."
Right now, he said, for things to change in hospitals, there has to be a greater push in terms of leadership, whether it's from governments or hospitals.
"We have to make the case this is an achievable goal and we can do it," he said. "Why aren't we requiring hospitals to invest in resources necessary to do this? Why don't we shame people who say they don't have time?"
Baker said there are hopes the initiative can also address the different kinds of infections that have been sweeping through hospitals, such as C. difficile and methicillin-resistant staphylococcus aureus, but acknowledged that's going to be a bigger job because those bacteria are so entrenched in hospitals. For now, he's still trying to convince doctors to remember the basics – like washing their hands every time they see a new patient.
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