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Mistakes That Kill
Uncounted thousands of Canadians die each year because of avoidable medical
errors. A program is just beginning to monitor the errors and eliminate the causes.
ON JULY 30, 1996, Nancy Brown witnessed her son's death by the same lethal injection that is used for executions in the United States -- potassium chloride. The setting, however, was no death row but the supposedly curative premises of Leamington District Memorial Hospital in southwestern Ontario. Jeffrey Brown, 33, undergoing treatment for a kidney infection, was chatting with his mother and a friend when a nurse arrived with a medication cart. Brown was supposed to receive an injection of lasix, a drug used to reduce swelling caused by excess bodily fluids. Instead the nurse somehow took a vial of concentrated potassium chloride from a drawer in the cart, filled a 20-cc syringe and injected it directly into Brown's vein.
Brown, who had taken lasix previously, immediately knew something was wrong. "Please stop," he cried out. "You're hurting me, it's burning, it's making me dizzy." But the nurse continued, saying she was following doctor's orders. Even when Brown pulled his arm away and threw it above his head, the syringe still lodged in his vein, the nurse forced it back down to finish the injection. As Brown began to gurgle and lose consciousness, the nurse went to find her supervisor on another floor. Brown's father, Paul, arrived shortly after the supervisor. Alarmed at his son's lifeless appearance, he shouted: "He's not breathing." The supervisor insisted Jeffrey's breathing was just weak and shallow. She then asked the Browns to leave the room. A resuscitation team arrived, but Jeffrey Brown was pronounced dead.
The following morning, the nurse reported to her supervisor that she made an error. The autopsy found the cause of death to be an inappropriate infusion of potassium chloride, properly used in a much diluted form to treat a potassium deficiency. The nurse, who had 17 years' experience, was charged with criminal negligence. Two and a half years later, she was cleared of all charges. Nancy Brown is still trying to make sense of this "unfinished business," as she calls it. "My son died in a public institution and no one's been held accountable," she says. "I cannot heal until I am certain there are practices and procedures in place to prevent this ever happening again."
CLEARLY, THERE AREN'T. In hospital settings, where the guiding principle is the Hippocratic injunction "First, do no harm," thousands of Canadians -- credible estimates range as high as 10,000 per year -- are dying as a result of medical error. A further 10,000 deaths may result from infections acquired in hospitals and unanticipated complications from medications. Add to this an estimated 20,000 medication-related deaths in non-hospital settings. To put the total into perspective, the cumulative estimate -- 40,000 deaths per year -- is the equivalent of a jumbo jet crash every three to four days.
This horrific picture emerges when results of studies of the consequences of medical error and accidental death in the United States, Britain, New Zealand and Australia are extrapolated to the Canadian system. "There is no compelling reason to think the situation is any better in Canada," says Dr. John Millar, Ottawa-based vice-president of the Canadian Institute for Health Information. "Some people think there's reason to think it's worse, but the fact is, we don't know." Now, CIHI is trying to do something about that.
Working with the Canadian Institutes of Health Research, the health data management agency is launching the first-ever study to determine the extent of health-system error in Canadian hospitals. The research team will assess the availability of data that could serve to monitor and reduce the occurrence of error. Millar expects the researchers to report their findings by the end of next year. "We are looking to provide advice on how to routinely monitor errors," he says, "and to support a growing movement across Canada to reduce health-system errors and improve the quality of care."
The initiative is long overdue, according to concerned specialists. "Until very recently, Canada has largely ignored the maelstrom that has made the issue of patient safety a pre-eminent concern elsewhere," says
Dr. Peter Norton, who heads the department of family medicine at the University of Calgary. "Immediate steps are needed to address this failure." Dr. Jack Tu, senior scientist at the Institute for Clinical Evaluative Sciences in Toronto, decries the lack of a clear system for tracking medical errors. "Occasionally, something may happen in a hospital and that hospital will initiate a quality improvement review," he says, "but we're just starting to scratch the surface."
Certainly, health personnel are aware of the problem. In a U.S. survey conducted in March and April by the Robert Wood Johnson Foundation, a national philanthropic organization dedicated to improving health care, 95 per cent of physicians reported they had witnessed a "serious" medical error. On condition of anonymity, Canadian doctors told Maclean's of seeing the following:
• An elderly man is admitted to hospital with pneumonia and a history of emphysema and congestive heart failure. That night, agitated and unable to sleep, he's given what proves to be an inappropriately large dosage of a sleeping pill. His heart and lungs already compromised, he stops breathing and ends up in intensive care on a ventilator. A month later, he dies. No investigation is done.
• A woman arrives at a hospital emergency department, her face frozen in a twisted grimace. A doctor recalls that anti-psychotic drugs can have that effect. Questioning determines that the patient has been prescribed a drug, hydrochlorothiazide, to lower her blood pressure. But a pharmacist has misread the prescribing doctor's handwriting and, instead, given her an anti-psychotic drug, haloperidol, which can have serious consequences -- even a coma or death -- when misused. The woman is fortunate: given an antidote, she recovers over time. Again, there is no investigation or follow-up.
The problem, experts say, is that the Canadian health system does nothing to encourage "whistle-blowers" when something goes wrong. On the contrary, doctors and nurses fear the legal consequences of bringing their errors to the attention of authorities. Compared with other high-risk industries -- notably the airline sector, where safety measures and non-punitive reporting of errors and "near misses" are built into the system -- mistakes in the health-care sector are appallingly underreported. "Mechanisms to assure transparency and accountability have not been fully developed," says CIHI's Millar. The consequence: with errors seldom documented, root causes can remain hidden and no remedial measures are taken to prevent further harm.
Dr. Ed Etchells, a specialist in internal medicine at Toronto Western Hospital and board member of the Canadian Institute for Safe Medication Practice, emphasizes the urgency of creating "a culture of safety rather than a culture of blame." The main requirement, he says, is a confidential, non-punitive reporting system. "All health-care professionals want to bring safety concerns forward," says Etchells. "They just need a mechanism to do so."
Another essential step towards ensuring patient safety is implementing computerized systems throughout the $95-billion health-care sector. "Imagine walking into your bank to make a deposit," says Dr. Michael Guerriere, CEO of HealthLink, a Toronto firm building a clinical data network to link hospitals, "and watching the teller pull out a dusty ledger and quill pen to enter your deposit. That's where we are with health care right now." Doctors routinely cope with superhuman demands on their memory of patients' histories and on their ability to keep up with rapid advances in medical knowledge. Patient information is stored, on paper, in a multitude of locations, usually at the point of care. "As you go from one doctor to another, information doesn't travel with you," says Guerriere, "because there's no system to move the information and then get it back again."
Across the country, numerous pilot projects are under way to determine how best to make the wrenching, expensive shift from paper to computer over the next decade. Having physicians routinely transmit medication orders online would prevent errors due to misinterpretation of handwriting and allow a double-check through the pharmacy department. Dr. Matthew Morgan, a specialist in internal medicine at Toronto General Hospital, says a linked electronic system would also alert doctors to possible complications involving particular patients and medications. "The pen and prescription pad are killing people," he says.
"We need to get moving faster," adds Morgan. "We need increased investment, we need ways to support changes in culture so this is not a blame situation but more an opportunity for improvement." The new national program to address the critical issue of medical error is a start. But for Nancy Brown and
thousands of other Canadians living with the heartbreaking consequences of mistakes, there is only the memory of a tragedy. Five years after her son's death, she says, "It's on my mind every day."
The Institute for Safe Medication Practices posted this prescription on its Web site as an example of how doctors' unclear writing can lead to errors in medication. It calls for a patient with renal failure to be given a dose of the antibiotic vancomycin, along with orders to administer another one-gram dose intravenously if his vancomycin level the next morning is "<10," meaning less than 10 milligrams per litre. But the "less-than" symbol is written in a way that makes the number 10 look like 40. The posting does not say whether the patient actually received the wrong dosage. A single dose that size is unlikely to cause harm, but prolonged excessive dosing could lead to kidney damage, ear damage or blood problems.
STORING MEDICINE THAT KILLS
Mistakes with potassium chloride like the kind that killed Jeffrey Brown have happened elsewhere and could happen again, unless steps are taken to reduce the risk. In six of eight cases reviewed from 1996 to 1998 by the U.S. Joint Commission on Accreditation of Healthcare Organizations, concentrated potassium chloride was mistaken for some other medication, primarily due to similarities in packaging and labelling. The most effective way to prevent errors, the commission found, is simply to remove concentrated potassium chloride from patient-care areas.
Like many other institutions, Toronto Western Hospital has done just that. Nursing units now stock only diluted solutions, which are used to treat potassium deficiency. Physicians wanting to have potassium chloride administered to a patient have to write their orders on standardized forms specifying the pre-mixed solutions. Meanwhile, the hospital's frontline medical, nursing and pharmacy staff have been re-educated about the causes of medication mistakes. The hospital made the changes not only to protect patients from risk of error, but to help staff avoid circumstances in which they could commit an error. "Good people can make mistakes," says Sylvia Hyland, the hospital's manager of pharmacy operations. "Words cannot express the devastation they can feel."
THE BOTTOM LINE
Besides their harmful effects on patient health, medical errors are expensive. While Canadian data are hard to come by, U.S. studies from the late 1990s calculate costs (in Canadian dollars) to that health system:
• Patients suffering adverse reactions to drugs stayed an additional 2.2 days in hospital with an increased cost of $4,866 per patient • Total annual health-care costs for preventable adverse effects: $31 billion
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