The Winnipeg Regional Health Authority's former head of patient safety says changes that have been made to protect emergency room patients are "piecemeal" solutions.

Dr. Robert Robson was the WRHA's chief patient safety officer from 2003 to 2009, tasked with ensuring patient safety initiatives were implemented.

Health Sciences Centre ER

The adult emergency room at Winnipeg's Health Sciences Centre was where Brian Sinclair died in September 2008, after waiting 34 hours without being triaged or receiving care. (CBC)

He was part of an emergency care task force that in 2004 produced a report following the death of Dorothy Madden, a 74-year-old woman who had waited six hours to see a doctor at St. Boniface Hospital.

Among the task force's recommendations were calls for a reassessment nurse — an advocate of sorts for ER patients and their family members — and an electronic triage system.

"That kind of recommendation falls into the category of piecemeal or patchwork solutions, treating health care as if it was a car where we just find the broken part," Robson, who is now the principal adviser with a private firm, Healthcare System Safety and Accountability Inc., told CBC News in an interview.

"The truth of the matter is that most of us on the committee were still looking for the quick fix or the bandage solution."

Robson was still in charge of patient safety at the WRHA when Brian Sinclair died in the emergency waiting room of the Health Sciences Centre in September 2008.

Sinclair, 45, had gone there for a blocked catheter and a urinary tract infection. He died in the hospital's emergency department waiting room on Sept. 21, 2008, after sitting for 34 hours without receiving care or being triaged.

While Robson did not work on the review into Sinclair's death, he said recommendations were made that were similar to what came out of the 2004 review.

Systemic issues

Recommendations from the 2008 review included greeting everyone who comes into the ER and making sure everyone is spoken to every four hours.

However, Robson said the ER problems that were identified in light of Sinclair's death are nationwide and much broader than anyone realizes.

Lori Lamont

Lori Lamont, the WRHA's vice-president of interprofessional practice and chief nursing officer, says some of the measures that have been implemented in recent years are taking some pressure off emergency rooms. (CBC)

"The biggest study that was done suggested that for adults, one out of 13 of them entering an acute care hospital would experience some breakdown in care that resulted in harm. That's 7½ per cent," he said.

"A more recent study that was done in pediatric hospitals suggested that the incidence was even higher, so that one out of 11 children being admitted to a hospital would experience some kind of an adverse event with harm. Now, this should be a national … tragedy, I suppose."

He said attention needs to be paid to systemic issues such as why emergency rooms are often overcrowded in the first place.

"Health care is not a car assembly line," he said.

"So we need to think about these things in a very integrated fashion that doesn't simply say, 'Oh, here's the problem, let's add more beds' or 'Here's the problem, let's close down this.'"

Lori Lamont, the WRHA's vice-president of interprofessional practice and chief nursing officer, agreed with Robson on that point.

"I would agree with him. They aren't, in and of themselves, going to fix the root cause of some of the difficulties," she said in an interview Thursday.

At the same time, Lamont said some of the measures that have been implemented in recent years are taking some pressure off Winnipeg's emergency rooms.

Robson said officials should be taking a different approach.

"It's not going to have any long-term impact until we address the underlying issue, and that is a very broad systemic issue of people [coming] to the emergency department — some of them quite sick — and we often don't have any place to put them," he said.

Work in progress

Lamont said work on that issue — called "patient flow" by the WRHA and "access block" by Robson — is a work in progress, with staff looking at three areas of concern.

"What can be done upstream, before people enter the emergency or the acute care hospital?  What can be done to improve our processes, both within the emergency and within the in-patient areas? And then, what do we do to make sure that when people no longer need those acute care services, they can move out of the acute care hospitals in a timely way?" she said.

Lamont said while the work has begun, it will take time to see measurable results.

An inquest is currently underway in Winnipeg to examine the circumstances surrounding Sinclair's 34-hour wait in the emergency ward.

Robson said he has asked several times to be included on the inquest's witness list, but he has yet to be called to speak.

He said the inquest should stay away from assigning blame and instead look at how emergency rooms normally function — when things go right — and see what lessons can be learned from that perspective.

"What we should be doing is not looking for culprits, but we should be looking for understanding," he said.

"If what we're doing is trying to understand a situation, we will ask an entirely different set of questions and we will go down very different pathways than if we start out focusing on who messed up and what went wrong in this particular case."