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Medical Mistakes

A landmark 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.

The Canadian 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

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 events.
  • 87,500 patients admitted annually to Canadian acute care hospitals experience an adverse event (mistake).
  • 1:13 adult patients admitted to a Canadian hospital encounter an adverse event.
  • 1:19 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 error.
  • the most common areas for an adverse event to occur was surgery followed by medicine related errors.

The Need for Disclosure

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 medical culture.


Adverse events 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 processes.

There are a number of steps which must be taken urgently to reduce injuries caused by our system. Here are a few recommendations:

  • Comprehensive reporting standards must be developed to ensure that errors are disclosed to the patient and tracked for future safety initiatives
  • Patient 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 training
  • Every hospital needs to develop a a comprehensive patient safety strategy and hospital accreditation processes should include an evaluation of patient
    safety programs.


Medical Mistake is an important public health issue. It is a significant risk factor, associated with a demonstrated frequency and there are clear opportunities for prevention.

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.


Last modified 10/10/07



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