A new report on patient safety has revealed flaws in our hospital system that should trouble all of us. Last year, according to the Canadian Institute for Health Information, 138,000 people country-wide experienced harm while in hospital. One in eight of these patients died 鈥� a total of 17,250 fatalities.
Medication errors are a leading cause of these injuries. Every year, 50,000 Canadians suffer this form of harm, which might include being given the wrong drug or the wrong dose.
(鈥淣ear misses鈥� are also counted, where a fortuitous event, such as the nurse being called away, prevents a mistake from happening.)
This year, in Ontario, there was an example of how devastating errors like these can be. A young boy with a sleep disorder was incorrectly given a drug intended for a different condition. He died of a dose three times the lethal amount for adults.
This blunder was caused by a pharmacy, not a hospital, but it points to a growing risk. Drugs today are often more powerful, and more narrowly targeted at individual patients, than those available a few decades ago.
Extreme care must be taken with their use. Evidently, as the study shows, that doesn鈥檛 always happen. (A study in the U.S. found hospital errors are America鈥檚 third leading cause of death.)
But here, a different kind of problem emerges. While CIHI collected data nationwide, the institute is not releasing the error rate for individual hospitals. All we are shown is a national aggregate.
Other than causing alarm, this accomplishes nothing. What benefit do residents of Victoria or Nanaimo gain from a cumulative total that mashes together figures from across the country?
The reason offered is hardly reassuring. Apparently, this is the first time CIHI has attempted to assemble a database that combines all forms of harm. Hospitals are being given time to digest the numbers and suggest improvements, before the public gets to see them (if we ever do).
But why did it take until now to create what should be a standard measurement tool in any modern health-care system?
It gets worse. For several years, CIHI has maintained a separate database where hospitals can report adverse incidents. But the process is purely voluntary, and the public is not allowed to see those numbers, either.
Now let鈥檚 turn to British Columbia. Health authorities in our province do keep a record of medication errors at each of their hospitals.
However, once again, this information is not made public. We asked authority staff to show us the data and were refused. We asked how many patients die of such errors, and were told that information cannot be released.
Two reasons were given. Caregivers might not report their mistakes if the facts are made public. And since this reporting system is also voluntary, there鈥檚 no way to know how reliable the numbers are.
These are legitimate concerns. Health-care agencies do good work under extremely difficult circumstances.
Nevertheless, this is unacceptable. People have a right to know what risks they run when hospitalized. They have a right to know which facilities perform well and which do not.
That is why misadventure rates must be open to the public 鈥� so lax behaviour is corrected by force of public pressure.
Our country鈥檚 system of hospital reporting, built up over 20 years at a cost of several billion dollars, rests on one central premise: That health-care professionals believe in performance measurement and can be trusted to disclose the facts, even when the facts aren鈥檛 necessarily palatable. When it comes to reporting medication errors, this principle has been abandoned.
A firmer hand is needed here. Staff sensitivities are important. But patient safety must come first.
