Canada's Best Kept Secret
Each year, 3000 Canadians die in car accidents, 16,000 from stroke, and 23,000 from preventable medical error. Just let those numbers sink in for a moment. Preventable errors are outright mistakes made by healthcare workers and are very much different from death that is caused by the original injury or illness. As reported in a 2006 research survey, 77% of hospital managers, 75% of nurses, and 40% of doctors feel that someone is likely to be subject to a serious medical error while being treated in a Canadian hospital. Indeed, about 70,000 Canadians are injured each year as a result of medical error.
If we look only at how many times Canadians have had to return to the hospital or extend their hospital stay because of a medical mistake, that time amounts to an extra 1.1 million hospital days per year in Canada. At approximately $5500/day that's about $6billion or our precious taxpayers' dollars, each year, devoted to covering preventable medical error.
In the United States, an Institute of Medicine report in 1999 raised alarm bells when it reported that some 98,000 Americans were dying each year from entirely preventable errors. Back then, that number shook the healthcare community like an earthquake, rocking the foundation of the medical establishment and resulting in desperate calls to correct the unacceptable reality of hospital error. Today, that 98,000 has soared to over 400,000 per year, making preventable medical error the third leading cause of death in the United States. Per capita, our numbers in Canada are not a whole lot better.
Why aren't Canadians up in arms about this patient safety emergency? Well, the obvious answer is that most Canadians are simply not aware of the problem. And, it's not because Canadians don't care about an issue that, statistically, will surely affect them or someone they love, it's because Canadian health jurisdictions don't wish to talk about it.
We have all manner of statistics on all sorts of life variables in Canada but when it comes to medical error, mum's the word. Consider this: a 2004 study by Ross Baker and Peter Norton, estimated that the province of Ontario experienced nearly 72,000 adverse events and anywhere from 3500 to 9000 deaths in the year that the study was done. Of these numbers, only 29 adverse events were reported and only six deaths. The same study showed that in Alberta, there were no public reports of any adverse events or deaths whatsoever. It's not surprising that Canadians remain in the dark.
During a recent industry talk on high performance organizations, I discussed many of the most common excuses, provided to me, as to why healthcare institutions have not yet taken the bull by the horns on patient safety. Many of these excuses boil down to an all too common cynicism around hospitals -- that they are simply too busy and too complex to organize. I call it the 'too big to succeed' attitude. Yet, other high-reliability organizations, like airlines, air traffic control agencies, nuclear power plants, the military, and even Formula 1 pit crews, all have many hazardous moving parts and unforgiving operational environments -- and yet they all have found ways to row their boats in the same direction in order to substantially reduce risk.
One of the most common ways that high-reliability organizations do this is by learning from their mistakes and the mistakes of others. Of course, this means, first and foremost, admitting that error occurs, creating a safe way for people to report error without suffering blaming and shaming, and then recording and analyzing the data. High-reliability organizations pay attention to the details -- indeed, all the small threats that could combine to lead up to a bigger mistake. Conversely, many hospitals focus on reviewing large, singular, high-profile events, like fatal medication errors; or what hospitals call 'never events' or 'sentinel events'. Yet, for every 'never-event', there may be quite literally thousands of smaller errors or 'near misses' that could, under the right circumstances, lead to serious harm. There is much more to learn from numerous smaller events in terms of trends and threats than there is from one, highly improbable, 'sentinel event'. Paying attention to these little things and not just the big things is what I call 'listening to the whispers rather than the roars', and it is precisely what high-reliability organizations do everyday.
Building a mandatory error-reporting system that grants certain immunity for those who report their error is essential for building safer cultures and more reliable performance. It's the first step in creating meaningful data from which hospitals can learn to improve -- and ultimately build safer cultures.
While hospitals debate the merits of all this, the FAA and NASA's Aviation Safety Reporting System in the US aviation industry, just turned 40 years old this year, and is working like a hot damn. With new numbers on patient harm in Canada set to emerge this month, the media spotlight will surely be trained, once again, on Canadian hospitals. Given our track record on keeping errors a secret, any new numbers on patient harm are likely to come as a surprise for many Canadians. It's time for Canadians to stand up for more transparent and accountable reporting in our hospitals, not so we can blame and shame our healthcare professionals, but so we can help our system learn. Whether for reasons of ethics or economics, it's time to make the safety of every Canadian a national priority rather than a national secret.