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The Serious Reportable Events list outlines severe accidents and medical errors at provincial facilities since 2014. The province tracks 35 categories of possible errors, but only 13 types have been recorded so far. The Nova Scotia Health Authority won't reveal where the errors and accidents occur, again for patient privacy reasons.
By submitting a comment, you accept that CBC has the right to reproduce and publish that comment in whole or in part, in any manner CBC chooses. Nova Scotiaa€™s Annual Severe Accidents and Medical Errors Report reveals more than 130 incidents at hospitals and other medical facilities. Over the past 18 months, there have been 132 serious incidents or errors in the provincea€™s health care system, and it doesna€™t end well for the patient.
They can also include misdiagnosis, extreme bed sores, falls or foreign objects left in patients during surgery.
Hospitals have been tracking serious incidents and errors for years, but only now are reports being made public, a requirement since January 2014. However, if youa€™re looking for a diagnosis of where and why errors are happening, that information is not revealed. On Friday, the provincea€™s health authority spokesperson said they cana€™t reveal locations to protect patient privacy. But they do share the changes they are already making province-wide, such as fall prevention, medication reconciliation, and safe surgical checklists. The standardized tracking has not determined any trends, but is already providing a pulse on what is happening across the province, and how to protect patient care in the future. A new study published in the medical journal Anesthesiology found that almost half of surgeries at Massachusetts General Hospital, a leader in patient safety, had a medication error or adverse drug event.
Although that report was a great contribution to the field of patient safety, progress since it was published has been slow.
Since this study was conducted by in-house researchers at a leading hospital for patient safety, it opens the door for wider self-assessment, publication, and analysis of sources of errors and adverse events. The new study and media coverage around it will help to increase awareness of the need for greater patient protections.
Surgery on the wrong body part or patient, leaving a sponge in a patient, and giving a patient the wrong tissue, egg, sperm or blood product are among a new Canadian list of 15 "never events" for hospitals.
Health Quality Ontario and the Canadian Patient Safety Institute released their report, "Never Events for Hospital Care in Canada," on Friday to highlight strategies to identify and reduce medical errors resulting in serious patient harm or death, and that are preventable.
Leaving a sponge or towel in a patient after a procedure is on a list of 'never events' for hospitals in Canada. Surgery on the wrong body part or patient due to a mislabelled biopsy sample or because two patients have the same name. Wrong tissue, implant or blood product given to a patient, including blood or organs that are incompatible with a patient's blood type or the wrong donor egg or sperm. Unintended foreign object left in a patient, such as sponge or towel, after a procedure, regardless of whether harm occurred or if the object is discovered in hospital or after discharge. Patient death or serious harm due to a failure to ask whether a patient has a known allergy to medication or giving such a medication even when the allergy had been identified. Patient death or serious harm as a result of one of five pharmaceutical events, such as giving chemotherapy the wrong way. The report was written by a team who researched, surveyed and consulted with health-system leaders, providers, patients and the public before recommending a list. Forgetting to remove instruments and medical supplies from inside a patient after surgery is one of the more common errors that occurs in hospital. Anyone who has experienced the chaotic environment of a hospital has an acute sense of the many things that can go wrong.
The smell, it turns out, was coming from a gauze sponge that had been left inside her after she underwent an episiotomy, a procedure sometimes done during childbirth in which an incision is made in the perineum. It was Pannu herself who found and removed the sponge after weeks of enduring pain so bad that she said she found it hard to walk.
According to Pannu, she only discovered the sponge when she decided to examine herself after the antibiotics a family doctor had prescribed, thinking the stitches used to close her incision had gotten infected, didn't get rid of the pain or the odour.


He also said in the letter that he had been called to another delivery a mere 10 minutes after Pannu gave birth.
According to a claims management company representing the hospital's insurer, neither the doctor nor any of the staff present during the delivery are to blame for the mistake. The hospital refused to comment to CBC News on the Pannu case and said only that "any error that impacts patients is investigated and lessons are developed from the incident and built into action plans for patient safety improvement." Dr. Mistakenly leaving foreign objects in a patient's body is one of the most common errors that occurs during surgeries, followed by operating on the wrong body part.
Keeping track of the instruments used during a surgery is an important part of preventing errors. The checklists, devised by the World Health Organization in 2008, have been shown to reduce surgery-associated complications and deaths by more than a third and have been endorsed for use in birthing units by the Society of Obstetricians and Gynecologists of Canada. The hospital where Pannu had her baby has been using surgical checklists since 2009 and in a statement said it uses two-person teams to perform supply counts and quality checks in its obstetrics units. It found that 7.5 per cent of patients admitted to acute care hospitals in Canada in 2000 experienced one or more adverse events, which can include everything from reactions to wrongly administered medications to bed sores, falls, infections and surgical errors.
Saskatchewan was one of the first provinces, along with Quebec, to introduce legislation in the early 2000s obliging hospitals to report critical incidents, adverse events that result in serious harm or death. Reviewing incidents and spotting patterns of dysfunction is a key part of any attempt to reduce medical errors. Other hospitals have analyzed medication errors and found they often occur when nurses are interrupted so they had nurses start wearing brightly coloured vests when giving out medications to signal they should not be disturbed. Most hospitals require critical incidents to be reported at least to the hospital board and the affected patient or family members, but such events represent only a fraction of the mistakes and close calls that occur in any hospital.
In general, Canadian hospitals have only a very vague idea of how many errors are made in the course of delivering care because there is no standardized system for measuring and reporting them. Many hospitals rely on voluntary reporting of errors by staff, which has been shown to capture only a tiny proportion of errors. Medication-related errors, which are the second-most common medical mistakes after surgical errors, are tracked federally through the National System for Incident Reporting, but reporting is voluntary (although Ontario requires hospitals to report to the registry).
But in fact, despite the widespread adoption of "no blame, no shame" policies, health practitioners are not reporting errors as often as they should be a€” usually because they fear repercussions or have misperceptions about which incidents should be reported. Jurisdictions like Quebec, Saskatchewan and Manitoba that have been tracking critical incidents for years have found that while the number of incidents being reported has risen since reporting became mandatory, it still remains far below what research indicates it should be. But a method called the Global Trigger Tool, which relies on systematic reviews of patient charts by at least two health care professionals, was able to catch 90 per cent of the errors. Getting hospitals to examine the processes that lead to errors and near misses is a huge challenge, one that countries like Australia and New Zealand have been better at meeting than Canada, says Wendy Levinson, chair of the department of medicine at the University of Toronto.
One hospital that has dramatically redesigned its approach to medical errors is the University of Michigan Health System (UMHS) in Ann Arbor, which includes three hospitals and dozens of clinics and care centres. Boothman, the UMHS's head of clinical safety, put in place a new system of reviewing patient charts and getting each clinical service to report regularly on a series of patient safety indicators specific to their department. Red flags include things like the number of emergency department patients who end up in intensive care after being admitted to a ward or the percentage of surgical patients who are back in the operating room with 72 hours.
The health centre now preemptively offers patients financial compensation when it feels the standard of care has not been met, a method pioneered by the Veterans Administration Medical Center in Lexington, Ky. It's a brave approach, says Baker, the author of the 2004 Canadian study on adverse events. Part of changing the instinct to hide or contest errors is a willingness to disclose mistakes not just to patients but also to the public, and more and more hospitals are doing so on their own websites. Since then, other hospitals have come around to the idea and have started posting their own medical error data online. Most don't reveal specifics but give only annual tallies divided into broad categories such as "medication," "falls" or "equipment-related" (though the Winnipeg Regional Health Authority reveals some details in the "learning summaries" it posts online).
Giving a public accounting of errors is a sign hospitals are being more accountable but doesn't necessarily mean they're any safer, warns Baker.
The surgical team in the operating room at UCLA's Mattel Children's Hospital, August 5, 2002. The silence (which is well known in medical culture) came about in large part because of instructions from malpractice lawyers that anything said would be admissible in court.


Imagine how awful it must feel for patients who know or suspect a medical error has taken place, and then get the silent treatment?
But that gives way to a kind of weariness with having to keep answering the family's questions. The number one reason why patients and families sue doctors and hospitals is that they want to know what happened.
The push to communicate better with patients following a medical error is coming from the U.S. By submitting your comments, you acknowledge that CBC has the right to reproduce, broadcast and publicize those comments or any part thereof in any manner whatsoever. In 1999, the Institute of Medicine published the groundbreaking report, To Err Is Human, which revealed that between 44,000 and 98,000 people die from preventable medical errors in hospitals each year. By observing errors and events before, during, and after surgery, rather than relying on provider self-reports, it presents a more accurate picture of their frequency. While this is a bold and potentially risky move for hospitals, increased transparency is the best way to show where there is room for improvement.
Some studies estimate that surgery accounts for about 40 per cent of all adverse events, the injuries and complications that result from the care you get in hospital.
In a typical visit, most patients encounter dozens of small oversights a€” from a misspelled name on a medical chart to a misscheduled diagnostic test. She left the delivery room of the Trillium Health Centre in Mississauga, Ont., after giving birth to a baby boy in July 2008 with an object inside her that shouldn't have been there. Dalip Bhangu, met with Pannu after she went to the emergency department and reported what she had found. In a 2009 letter responding to the complaint, Bhangu said he felt sorry Pannu had to "endure discomfort" but that when he left the delivery room, the nurse, who is responsible for verifying that all instruments, needles and sponges are accounted for, assured him the sponge count was correct. It's one of the reasons why hospitals have adopted surgical safety checklists, intended to ensure that doctors and nurses follow a set of standardized steps before and after each procedure.
Hospitals have adopted something called a surgical safety checklist to help doctors and nurses do just that.
Most of these events did not result in any serious harm, the study found, but almost 37 per cent were preventable. Baker's work in Canada and that of some of his colleagues internationally was to bring it out into the light of day," said Deb Jordan, executive director of acute and emergency services for Saskatchewan Ministry of Health.
Department of Health and Human Services found that voluntary reporting caught only 14 per cent of adverse events suffered by Medicare patients in U.S. Brian Goldman is a practising ER physician and host of White Coat, Black Art, which returns with new episodes this fall on CBC Radio One.
Please note that comments are moderated and published according to our submission guidelines.
It is unique in that it is the first large study to examine errors before, during, and after surgery. That report underscored the importance of hospital errors by noting that this number is higher than the number of deaths caused by motor-vehicle accidents and breast cancer. The study also adds recommendations for reducing errors, such as limiting the ability of hospital staff to work around patient safety protections that have been put in place. While talking to a physician or hospital staff member about the safety measures they are taking to reduce errors and adverse events may seem intimidating, studies like this one can provide a starting point for the conversation.
Pannu said hospital administrators apologized but told her she was not entitled to financial compensation. The error rate it reported is higher than rates found in previous studies, probably because those studies relied on self-reporting by providers.
A later study found that medical errors that harm patients cost $17.1 billion each year nationwide. Information on how your hospital is doing is a vital tool in helping to become an empowered consumer.



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