patient safety study has found that there are up
to 70,000 preventable medical mistakes in Canada each
year. While Canada has one of the best
hospital systems in the world, this study highlights the
problems that exist in our system and demands change to
ensure patient safety.
Adverse Events Study
A recent study
published in the Canadian Medical Association Journal is
the most recent confirmation of an emerging epidemic in
health care. The article entitled: "The Canadian Adverse
Events Study: the incidence of adverse events in
hospital patients in Canada" was published in the May 25,
2004 edition of the journal.
As part of the
study, Ross Baker of the University of Toronto and Peter
Norton of the University of Calgary, together with 15
other researchers across Canada, collected and analyzed
data from over 3,700 patients in 20 hospitals.
The results of
the study confirmed the findings of similar studies in
the United States, Australia, the United Kingdom,
Denmark and New Zealand. Some of the highlights include:
- As many
as 24,000 patients die each year due to adverse
patients admitted annually to Canadian acute care
hospitals experience an adverse event (mistake).
adult patients admitted to a Canadian hospital
encounter an adverse event.
adults will potentially be given the wrong
medication or wrong medication dosage.
- 37% of
adverse events are 'highly' preventable.
- 24% of
preventable adverse events are related to medication
- the most
common areas for an adverse event to occur was
surgery followed by medicine related errors.
The Need for
One of the
clear implications of this study is that in the
overwhelming majority of cases, patients are not told
that there was an error in their care. Patients have a
right to be fully informed of their care, including
being told when mistakes are made. Hospitals and the
medical profession more generally must take positive
steps to move towards a system which encourages openness
to patients and objective analysis of medical errors.
This may well require a significant change in the
occur most often as a result of a series of failures in
an increasingly complex medical system. Consequently,
hospitals and health care providers must seek out
opportunities to improve their own internal systems and
There are a
number of steps which must be taken urgently to reduce
injuries caused by our system. Here are a few
Comprehensive reporting standards must be developed
to ensure that errors are disclosed to the patient
and tracked for future safety initiatives
safety initiatives must receive government support
and funding. Health facilities and agencies require
additional funds to develop and implement improved
patient safety systems, improve infection and
quality controls, and provide ongoing education and
hospital needs to develop a a comprehensive patient
safety strategy and hospital accreditation processes
should include an evaluation of patient
Mistake is an important public health issue. It is a
significant risk factor, associated with a demonstrated
frequency and there are clear opportunities for
We first need
to ensure that medical mistakes are reported to patients
and tracked to identify potential opportunities to
affect system . But there is also a pressing need to
re-examine and re-design systems to include safe guards
which can protect patients from the human fallibility
inherent in our medical system.