Shedding light on patient harm: Manitoba leads the way

2012-11-08

Eight years ago, Ross Baker and Peter Norton gave Canada a wake-up call about the harm being done to patients in this country’s  hospitals, through their report “The Canadian Adverse Events Study.” When we translated their findings to Saskatchewan, it meant that one or two people were dying every day as a result of adverse events in our hospitals.

While in our care, 300 and 600 people are killed every year. These are people’s grandparents, their mothers and fathers, their siblings, their sons and daughters. I thought, perhaps naively, that this sobering statistic would shake the health system out of its “mistakes are inevitable” thinking and agitate the public to say “what the…?”

It didn’t.  We have seen some promising and inspiring improvements in patient safety. But we’re far from being a health system where there is intolerance for any harm that befalls those whom we care for or those who provide the care.  We have a long way to go before we can say “Our first priority is zero defects” — a variation on the Hippocratic oath, courtesy of Dr. Otero of the Virginia Mason Institute in Seattle.

So why haven’t we moved faster to make care safer? Maybe it’s because the vast majority of discussions about patient safety and harm have been carried on quietly amongst ourselves within the system – rather than being shared broadly and regularly, including publicly.

That’s changing, thankfully.  At least in Manitoba.  I just learned of two amazing sites that demonstrate HUGE transparency.  The first  — on the website of Manitoba’s Health Ministry  —  provides detailed reports on critical incidents, with a few sentences describing each one. The second is a CBC News website that reports in detail on critical incidents happening in that province’s health care system.

In Saskatchewan, we say we’re committed to growing a culture of safety across our health system. Perhaps a good way to start walking the talk would be to follow Manitoba’s lead, and be absolutely transparent about the harm we’re causing to patients in this province.  Don’t you think it’s time to move this quiet conversation out into the open?

What did you think of this post? Did it affirm your view on the topic? Change your thinking? Let us know, using the Inspire-o-meter below.

 

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6 Responses to “Shedding light on patient harm: Manitoba leads the way”

  1. Donna Davis
    December 24, 2012 at 11:48 am #

    I applaud Manitoba’s lead and agree that Saskatchewan and all provinces should do the same. Learning can only be accomplished and tragedies averted if we share and speak openly about the harm to patients that occurs in our systems. The Global Patient Safety Alerts that was developed by CPSI, with the support of the Saskatchewan Ministry of Health, is a venue to share these learnings. The last time I was on the site, ISMP Canada and the Winnipeg Regional Health Authority were the only Canadian contributors. Very disappointing, when it is well known that sharing the lessons from critical incidents is vital to preventing a similar instance.
    In a 2012 report by William Charney it is stated that between 38,000-43,000 deaths related to health-care delivery occur annually in Canada. The well known figure of 24,000 reported in the 2004 study, and which has been widely used, was for acute care deaths only. Like Sir Liam Donaldson did in a foreward he wrote for a soon to be released (April 2013) Canadian patient safety book, “After the Error-Speaking Out about patient safety to Save Lives” by author Susan McIver, 40,000 is the number we’ll be using to include all the patients in our system who die from the care meant to help them. 40,000 or 24,000, the only number we can be content with is 0.

  2. Marie Everett
    November 13, 2012 at 3:03 pm #

    Bonnie, I thought when Dan started the Connecting the Dots session last month with the # of patients that had been injured in our hospitals during the previous 6 months and then detailing the 76 (I think that was the number) injuries that we had opened a door on true transparency within the Health system. I also thought it was huge when M. Davies took ownership of her region’s incidents. Now, to move outside the “inner” circle of healthcare and get it out in the public–that will be catalyst for advancing safety in the whole system. People just trust that, of course, the system is safe–they need to know that despite best efforts and sometimes less that best efforts, harm does happen. Keep up the good work. Marie Everett

    • Bonnie Brossart
      Bonnie Brossart
      November 14, 2012 at 7:09 pm #

      Hi Marie. I agree – some really promising behaviours at last month’s Connecting the Dots. I am hopeful that we will soon follow Manitoba’s excellent lead and share information on patient harm in Saskatchewan broadly. There’s no reason why we can’t or shouldn’t!

  3. Anonymous
    November 9, 2012 at 11:57 am #

    As someone who had a family member die in Saskatchewan’s health system due to delayed diagnosis and lack of appropriate treatment I appreciate the focus on the importance of ‘zero defects’. I often have a hard time when I hear of celebrating decreases in critical event numbers. Yes, we may be improving and it’s important to recognize improvement, but as you mention, one critical event is one too many. It is someone’s family member. Some individual who may have had hopes and dreams and plan for the future.
    Thanks for your article Bonnie, it is nice to see health system leaders focusing on this.

    • Bonnie Brossart
      Bonnie Brossart
      November 9, 2012 at 12:31 pm #

      Thank you for sharing your story. I am so sorry to hear of your loss. Safety statistics while important – can unintentionally mask the tragedies. This is why I so like Dr. Otero’s quote: zero is the only number that we should tolerate.

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