Monday March 17, 2008
In 1999, the US-based Institute of Medicine published a report on medical errors at American hospitals. The report was entitled "To Err Is Human." No one is perfect, right? So, why would you expect the people who take care of your health needs to be any different?
The scale and impact of medical errors are staggering. The US report estimated as many as 98,000 people die in hospital each year as the result of preventable human errors. And Canadian hospitals are not necessarily safer. In 2007, a report on patient safety by Canadian Institute for Health Information (CIHI) found that 1 in 10 patients receive the wrong medication or the wrong dose, and another 1 in 10 contract an infection (often a superbug) while in hospital. What is most concerning is just how inured the people who work inside the system are to medical mistakes. The CIHI report found that more than 7 in 10 nurses and nearly 8 in 10 hospital managers say patients are likely to have a serious medical error while receiving treatment at a Canadian hospital.
This week, on White Coat, Black Art, we present some jarringly honest confessions from doctors and nurses on the front lines who have made medical errors. All of us -- me too -- have done things or have neglected to do things that have cost people their well being and in some cases their lives. Some of those stories will make you angry. But, it is my hope that those confessions will make you understand something that the media with its "outside-in" perspective often fails to tell -- that medical errors are also devastating to the doctors and nurse and pharmacists and others who commit them. I want to thank those who were brave enough to tell their stories on the show.
But there's more to the show than mere confessions. Seventy years ago, airplanes became more complex and harder to fly. As a result, pilot error and accident rates went up. That's when the fledgling military and civilian airline industry came to an important conclusion: that they'd have to find ways to make flying safer, or accident rates would climb. Over the years, billions of dollars and untold hours have gone into creating what's known as a "culture of safety" in flying. The result? Accident rates are considered acceptably low.
This may surprise and anger you, but there is no such "culture of safety" in hospitals. Avi Parush, a human factors engineer who once helped design fighter aircraft cockpits to make them safer for pilots to operate, has turned his attention to make things safer in a hospital operating room. Parush says it is only now that experts are starting to look at the way doctors and hospitals operate to find ways to reduce preventable errors. I found Parush's interview both revealing and troubling.
And next week, for those of you who want to sue your doctor, we'll give you an insider's look at what you're up against as you try to win your day in court.
Previous Comments (15)
Medical errors are something most patients fear. I've had many conversations with patients about how they feel about their treatment.What i hear alot is; "Whatever they want to do. I don't really know what they are doing or what's going on. I just want to go home soon." Or, the patient speaks in pure frustration because the procedure that was done,was explained to them shortly after the surgery and still in the fog of anaesthetic. This is usually the case because that is when the Doc had time to explain what happened to their bodies, and the patient didn't have the presence of mind to ask alot of important questions. This also leads to medical error, as the patient can't remember the signs and symptoms to look for if complications were to arise. To date, we have had a number of patients back to have the previous procedure "redone." As a recent patient myself,(again), i had a work place accident and was not given follow up instructions, offer of pain medication,or a history taken. I know better, did they know that i knew that? Were they lucky that i knew how to control pain and knew how to treat my injury at home? This isn't the first time for me either. When i was 18, I had 2 GP's and one ob/Gyn tell me that my excruciating pelvic pain was my attempt to get "attention." Almost one year later, upon visiting yet another new GP to find out what was going on with me, she did the exam, she asked the questions, she listened to what i had to say and she discovered a rather life changing diagnosis. She had me in surgery within the week. I am not "fixed" and because of all the past ignorance i have permanent, constant discomfort/pain which affects my life every day. Emerg is tough when you are under pressure with a screaming patient that won't stop long enough for you to get a history(all though you just gotta find a way), or has lost conciouness and there isn't a "person" to ask; be very careful when doing anything. But these GP's had the time to get what they needed from me and other patients. The conclusion from the study that the history can lead to wrongful pre-diagnosis is exactly true and i can say that alot of us are guilty of it, i know i have been. But LISTENING is really the key here. Get the history and place it in the back of the mind and LISTEN to what is going on NOW. Constipation and palping the abdonmen for the appendix...come on!Sophia, March 17, 2008 2:26 PM
Hello White Coat! If you do read this, please use the pseudonym Morgan Scarf - my name is fairly well known here.
Question: are there statistics gathered on how many deaths might be attributed to one specific person (doctor, nurse, etc.?) If so, where might I find them.
Thank you - marvellous show!!!
To my knowledge, there are no stats on medical errors by individual physicians. However, in the US, there are stats on hospital and individual complication rates. Now, complications are not necessarily caused by error., but that's the closest to answering your question that I can think of. The other thing that's worth mentioning is that higher complication rates do not necessarily mean that the surgeon has a problem. Higher rates may mean the surgeon sees sicker patients, and sicker patients tend to have higher complication rates.Brian Goldman, March 17, 2008 3:47 PM
Over the past few years, there have been many news reports of medical "professionals" taking part in the unauthorized removal, stealing and selling of body parts from unsuspecting patients and non-patients alike, dead or alive. The world-wide trade ( buying and selling ) and stealing of body parts is a multi-billion dollar "business". Everyone from nurses and ambulance drivers to doctors, surgeons and even morgue attendants and funeral home operators have been caught participating in these crimes. These illegal activities engaged in by medical "professionals" have taken place in many countries and on every continent. If any of you think this happens only in poor countries in Asia, Africa and South America, then you need to get your head out of the sand, give it a good shake and open your eyes. Since in the wealthy industrialized world we, in Canada, are near the bottom when it comes to "patient safety" ( medical errors, negligence, poor hospital hygiene etc. ) why would we think that in other "problematic" areas of our healthcare ( like body parts stealing by medical "professionals" ) we would be so much safer? Sadly, the worlwide human body parts "business" is similar in many ways to the auto parts business. "Parts" are bought, sold, exchanged,stolen etc., and the "parts" dealers ( junkyard operators and some doctors ) have phone "hotlines" etc. to exchange "parts" information. Our "holier than thou" and "business as usual" medical institutions/hospitals etc. have lulled us into a false sense of security. The recent news reports about a doctor in Canada involved in stealing and/or buying and selling of hundreds of kidneys from other countries is just the tip of the developing iceberg. Just keep your eyes and ears open.Mark Mager, March 17, 2008 7:01 PM
In all my years as an RN, I saw only one doctor who had the courage to admit a mistake and discuss the situation with patient and family. This specialist, by the way, also took time to listen to and act upon the input of nurses! I don't believe that guidelines are needed here, just some honesty and courage and support from the community when honest mistakes are made. When mistakes occur as a result of negligence, incompetence, laziness or lack of caring, on the part of any member of the team, then that member should be censured, given an opportunity to change behaviors and, failing that, removed from the team. Even when everyone on the health care team is aware of problems with one of its members, it is very, very difficult to effect a change in practice and/or remove that person. Commitment, communication and honesty are all that is required. We all know how to make apologies, it's just that it is difficult and we don't like to do it.Joan Richard, March 21, 2008 3:05 PM
If I told you that I have made many mistakes in my profession that were undected,unreported and deliberatly hidden from my patients you may be shocked. Most people would like to believe that honesty would be a priority in the health care professional at all levels. It is unfortunate that most mistakes are not reported to the general public and in truth it is most likely not to change until a culture of disclosing error is not met with punitive or litigious measures but rather with a focus of using our mistakes as a risk management tool to aid in preventing future similar mistakes.susan rn, March 22, 2008 12:58 AM
Sophia has some excellent points. Listening is so key. I once turned up at an emergency room with intractable, crippling biliary pain (a recurring issue, and yes, my gallbaldder is long gone). It's a distinctive pain, up under the right ribs, going around to the back, sometimes referred to the right shoulder. One ER doc, who seemed to have made up his mind I was only after narcotics, asked me if the pain could be related to my period.
Another doc, during another visit, blatantly told me I was lying about my pain, that it couldn't possibly be as bad as I claimed. It turned out he hadn't bothered to look at my thick file. So I offered to wait outside while he did check my history, and then we could speak again. But it took a lot of guts to "defy" this doctor. I think he was having a very bad night, as someone died in emerg that night, but I did not deserve such spleen. A little while later, we sat down and talked again. I spoke softly, asked if he was having a rough night, and then he listened to me. Listening is a two-way skill. Doctors are not our servants, but neither are we slabs of symptoms. I got a referral to a specialist, which was needed. Had I not spoken up, the doc would have just sent me home. Not a serious error, just delayed treatment, but still, an error.mbh, March 24, 2008 8:35 AM
A serious medical topic not often discussed is that of people (young and old) who have to live with various "life supporting systems" such as; brain (drainage) shunts, feeding tubes, oxygen supply devices etc. Some of these life supporting devices, such as brain shunts, need proper, regular and timely monitoring by medical specialists (experts in that field) not some worthless (in this case) yearly "family doctor" visit. According to medical brain shunt experts, these devices have a 90% failure rate within 10 years of being "installed" in the patient. Therefore it would not be "rocket science" to realize that these shunts should be repaired and/or replaced or at least closely "monitored" by brain shunt experts. But this obvious solution would be too simple for our "learned" and "beyond reproach" medical community. They have a better solution for our patients with brain shunts, just "keep your fingers crossed" and hope for the best.
Recently there was just such a case in London, Ont. A young man, in his early twenties, with a brain shunt that was at least 15 years old ( therefore with a failed shunt, according to brain shunt experts) was not quite his usual lively and energetic self. The "respite provider", who was to look after this young man for approx. 3 weeks, did not want to take a chance and, despite protestations from this young man, took him to a local hospital for a checkup/tests, just in case. After a 4 hour hospital stay and some "tests" the medical "professionals" at the emergency dept. claimed/concluded that the "symptoms" did not point to any shunt problems and sent this young man home.
Apparently, these medical E.R. professionals even suggested that it may be "just sore muscles" or a cold etc. The "symptoms" this young man exhibited did not go away but got worse a few days later. He was taken to the hospital again, this time by ambulance. However, this time it was too late. Tragically, this young man passed away a few days later from brain shunt failure. This tragic "misdiagnosed and sent home to die" hospital scenario repeats itself hundreds of times every month in Canada. Of the approx. 3,000 patient/victims killed by our hospitals ( misdiagnosis, negligence, medical errors etc.) every month across Canada, at least 100-200 patients are victims of this classic "misdiagnosed and sent home to die" hospital error. Dear Dr. Goldman, what can you tell your audience about the problems with brain shunts?Mark Mager, March 31, 2008 4:56 PM
I am a huge fan of your show. I think you do a great job of demystifying what goes on behind the scenes in the Canadian health care system.
I really enjoyed your episode on Medical Error. I am very pleased that you pointed out the issue of “safety culture” which far too many organizations dismiss. Despite years of investments in clinical training and guidelines, information technology, process redesign, and industry regulations, “organizational culture” remains one of the key root causes of safety issues and medical error. To change this, an organization needs to change its culture to one where every staff member recognizes his or her responsibility to maintain and improve patient safety.
Hopefully your documentary will help promote the need for improved safety culture.
Agili-T Health Solutions
There is a seldom talked about problem of alcohol and/or drug abuse by some of our medical professionals. Now, on the surface of it this would not be a "big deal", right?, after all it is a societal problem not just a medical problem. However doctors, surgeons and other medical professionals have our lives literally in their hands. The various "studies", "statistics" etc. indicate that approx. several thousand of our medical professionals are alcoholics and/or drug abusers. However, they are not forced to go to "rehab." and they are not "fired". This means that a doctor/surgeon may be performing medical "procedures" or even surgeries while drunk or high on some drug. Now, we know that our hospitals kill approx. 24,000 patients every year by medical "errors". We can only guess how many of those deaths are attributable to some of our doctors'/surgeons' alcohol/drug addictions. Dr. Goldman, can you tell your audience how our medical establishment deals with this problem? Are the potential patient/victims ever warned about their doctor's addiction problem?, or is it all just "hushed up" and covered up by other fellow medical professionals?Mark Mager, April 11, 2008 9:03 AM
Thank you for your most recent posting. You've raised an important subject -- that of the impaired health professional. Doctors, nurses, dentists, pharmacists etc are no different from everyone else. Thus, it's no surprise that an estimated 5-10% of health professionals -- like the general population -- has a chemical dependency.
While it's tempting to assume that medical mistakes are caused by impairment, that's not what the studies suggest. In fact, impairment on the job is a very late manifestation of chemical dependency. Most health professionals maintain competency at work in spite of chemical dependency.
Is the problem kept "hush-hush", as you suggest? That it's not trumpeted may reflect the feelings of shame that are evoked by the subject. But there's a more important issue at work here.
The old style traditional way that regulators dealt with the problem of chemical dependency was to shame health professionals and to take their licenses away without much recourse. That may sound good, but the results in terms of protecting the public were dismal. All that shaming and punishment tended to make health professionals work harder to HIDE their dependency. It also made colleagues and friends far less likely to report it since the consequences were so grave to the doctor.
In the past 20 years, regulators came up with a new concept: do an intervention on the doctor and offer he or she sanctuary from punishment in return for meeting contract conditions such as going through a chemical dependency program, going to meetings, and submitting to random urine drug tests.
The result? Much higher rates of reporting and dealing with the problem. Turns out health professionals take great pride in their work; relapse rates are much lower in health professionals than in the general population, largely because health professionals have so much at stake if they continue to use.Brian Goldman, April 11, 2008 9:28 AM
As was pointed out earlier, on your show, Canadian hospitals do not operate in a " culture of safety ". When Canadian patient/victims are sickened, injured, maimed or killed by a myriad of hospital wrongdoings ( medical errors etc. ), there is little or no accountability for those tragedies.
Hospitals/medical professionals are not presently required to tell the truth/disclose any and all wrongdoing on their part that led to those tragedies. Instead of a "culture of safety" what we have in Canadian hospitals is a "culture of blaming the victim", or the family of the victim, the hospital just injured, maimed or killed by medical errors, misdiagnosis, "poor hospital hygiene", deadly hospital "super bugs" etc. The result is an atrociously high number ( 36,000 ) of patient/victims killed by our hospitals every year and a very small number of law suits because patient/victims and their families are kept in the dark about what really happened to them.
The above number means that Canadian hospitals kill approx. 100 ( one hundred ) patient/victims every day. That is a horrific number and is much higher, per capita, than is the case in many other wealthy, industrialized countries. This lack of medical errors "disclosure" prevents our Canadian patient/victims from getting the compensation/justice that is rightfully owed to them.
A sad example of this heartless and cruel "blaming the victim" hospital practice was the "treatment" received by the mother of a child injured, by the hospital, during delivery at --------- Hospital in ---------------, Ontario. The negligence of some medical staff at ---------- Hospital caused cerebral palsy in the just born child. So what did this hospital do?, it blamed the mother of that child, of course, by cruelly telling her that she caused the cerebral palsy in her just born child due to a "virus" in her womb. Thankfully, this cruelly victimized mother of a child injured by --------- Hospital won a $ 5.3 million dollar lawsuit against that hospital.
Similar horrific scenarios are repeated in Canadian hospitals thousands of times every year and most of those patient/victims never get the compensation/justice that is rightfully owed to them. This is because hospitals/medical professionals in Canada will not hesitate to cover up, blame the victim or the family of the victim, give out misleading or even false information in medical records, "doctor" the records, or in any other way try to "wash their hands" of the tragedy they caused. All in an attempt to avoid accountability/responsibility for their own wrongdoing and to prevent their patient/victims from ever getting the compensation/justice they deserve. Signed, Mark Mager, of London, Ont.Mark Mager, April 24, 2008 10:19 AM
Sixteen years ago my wife Dorcas experienced excessive brain fluid and under went a shunt surgery, having been diagnoised, hydrocephaleus. Life qualities improved for many years. Recently similar dibilitating signs reoccured. She is 74 years of age and it is likely she will undergo another shunt surgery or revision. Can you tell me where to go for information affecting aging persons. So far most of what I read involves children. ThankyouGerald Hawkes, May 12, 2008 7:13 PM
We need a " PATIENTS BILL OF RIGHTS " in Canada to make it easier to get compensation/justice for victims of any hospital/medical institution/medical professional wrongdoing which leads to any illness, injury, or death of the thousands of patient/victims all across Canada every month. This " PATIENTS BILL OF RIGHTS " should prevent and prohibit the undue and outrageous misinformation, cover-ups, delays with medical records and "blaming the victim" tactics often used by hospitals against those very patients they have wronged (sickened, assaulted, injured, maimed or killed) by medical errors, negligence, misdiagnosis, deadly hospital "super bugs", abusive medical professionals etc. Canadian hospitals employ a so-called " risk management " (smoke & mirrors, whitewash and spin) offices to mislead, deflect and cover-up their wrongdoing in hospital caused deaths and other tragedies. Many cases of medical malpractice are so obvious and straightforward that the patient/victims in those cases, or their families, should not have to use the expensive and time-wasting process of "litigation" through the courts in order to get the compensation/justice they deserve. The " PATIENTS BILL OF RIGHTS " would "streamline" the process of compensating patient/victims without having to resort to medical malpractice litigation, at least in those "obvious" cases of hospital/ medical wrongdoing. The more difficult, complicated and contentious medical malpractice cases will still be allowed to use the more costly, to all of us, legal/court system. Signed, Mark Mager, of London, Ontario.Mark Mager, May 19, 2008 1:11 PM
We already know that "poor hospital hygiene" and the lack of proper/serious patient safety measures in our Canadian hospitals kills approx. 12,000 (twelve thousand) patient/victims every year in Canada. Hospital hygiene problems result in such deadly hospital bacteria and "super bugs" as flesh-eating disease, C. difficile, staph and streptococci infections. However, the most recent "hospital horror" story, just coming to light, is that of contracting the nasty and horrific "mad cow disease" as a result of "surgery" in a hospital. Yes, believe it or not, you may now receive "mad cow disease" courtesy of a hospital near you. You now can get this horrific disease even if you have never chewed on a chunk of beef in your life. Until now, most of us thought that you actually have to eat some mad cow-diseased beef to get this disease. Well, now our hospitals with their amazing ability to bring to us new, strange, exotic, bizzare, horrific and deadly diseases, have found some strange, and as yet not fully explained, way to give us "mad cow disease" even if we did not eat any "cow". Now, some unfortunate patient/victim who goes into some unfortunate hospital hoping to "receive the gift of life", may instead receive "the gift of mad cow disease". Dr. Goldman, could you tell your audience how this new "hospital horror" came about? Signed, Mark Mager, of London (our medical "Mecca"), Ontario.Mark Mager, May 28, 2008 5:43 PM