An "Adverse Event" or "Medical Error" is defined as: "an unintended injury or complication which results in disability, death or prolonged hospital stay and is caused by health care management rather than the patient’s underlying condition".
The first national study of patient safety in Canadian hospitals estimates that 7.5 per cent of people hospitalized in Canada have experienced an adverse event as a result of their care.
"The Canadian Adverse Events Study: the incidence of adverse events in hospital patients in Canada", published in the Canadian Medical Association Journal, found that the overall rate of adverse events in 2000 was 7.5 per 100 patient admissions, not including pediatric, obstetric or psychiatric admissions. This rate suggests that 185,000 of the almost 2.5 million medical and surgical admissions in Canada in 2000 were associated with an adverse event.
The study also found that:
- The majority of adverse events resulted in temporary disability or prolonged hospital stay.
- Five per cent of patients who experienced adverse events were judged to have a permanent disability.
- Adverse events were associated with death in 1.6 per cent of patients admitted to acute care hospitals.
- Surgical care accounted for the largest number of adverse events.
- Close to 37 per cent of adverse events in the study were potentially preventable.
Based on this, the researchers estimate there were 70,000 preventable adverse events across the country in 2000.
"Our study indicates that care in Canadian hospitals is safe for the vast majority of patients," says Prof. Ross Baker, PhD, principal investigator of the study and professor of health policy, management and evaluation at U of T.
"Safe for the vast majority"??? I wonder if reading this you are reassured that your odds of receiving safe care are well...not that bad...just cross your fingers and hope to die that you don't fall in the group of 185,000 people yearly who WILL experience "unsafe" care. At some point in your life it is very likely you will need hospital care of some kind. Are you reassured?
My Mother's Story:
Kathy Wiesner, just turned 65, was retired and was planning to move to the U.S. to marry a man she'd fallen in love with 3 years before. She lived in Calgary, Alberta and while she was finalizing her move, she began coughing. Thinking it was due to stress of the move, she ignored her symptoms and within one month after arriving in the States she decided to get checked. At first she was told she had Pneumonia. After 2 months she went back to the Dr. and was told it wasn't Pneumonia, it was Tuberculosis. She was put on medication for several months to treat the TB and when her symptoms didn't improve she finally had a Broncoscopy, a biopsy of the lung. On February 8, 2008, she was correctly diagnosed with Lung Cancer. I'll never forget the day she called to tell me. "Giovanna, I have lung Cancer and the Dr. said I need treatment right away". My mom didn't have medical insurance in the U.S. and she needed to come back to Canada for treatment. Four days later I flew to Illinois and brought her back to Vancouver to live with me and my husband. A few days later she had an appointment with an Oncologist and later that week started her first radiation treatment. She had only three radiation treatments when on Saturday, March 15, 2008 she told me she had a wish. She said "Giovanna, not that I don't appreciate your hospitality, but my wish is to go to the hospital and get the pain under control and then come home". I loved that through it all she was still able to crack a joke. That night I took her to one of the smaller, community hospitals in the Vancouver lower mainland and that's when everything went very wrong. Over the next two days, the healthcare providers accelerated the delivery of her medication at such a high rate that she became irreversibly toxic. Her body could no longer metabolize the pain medication and she suffered what is medically called "Opioid Induced Neurotoxicity".
Finally, on the third day, a Doctor who had not seen her to that point, saw that she was in trouble. Hours later she was transferred to the Vancouver Cancer Clinic. My mother swelled up like a balloon and later that evening we were told that my mother would not likely pull through. She died 3 weeks later, on April 21, 2008.
I cannot tell you the guilt I felt...for months. My mother was in my care. I felt I let her down. No matter what anyone tried to tell me to the contrary, I felt responsible for what happened, like I'd dropped the ball. I questioned whether I should have taken her to the Vancouver Cancer Clinic instead. I tortured myself, going back in my mind over and over all the details of those two days, feeling that if I had taken different action it would have changed the course of events. At the time I didn't know what was happening to my mom as the first signs of toxicity showed itself. I just knew something was wrong. The nurse called me at 1:30 a.m at home on the second night. "Your mom asked for you to come in". When I got there my mom was twitching and confused, desperately trying to tell me in broken words that "something went wrong". I asked her if she was in pain and she said "No." The nurse came in and said "Your mom is scared" and I said "No, it's more than that, something is wrong, call the Doctor". I met the Doctor in the hallway and pleaded with him, "please, something is wrong". "Your mother has Lung Cancer" he said. I was in utter shock at his words. I left him standing there in the hallway and went back into my mom's hospital room. I never saw him again. He simply walked away.
After my mom's death I fell into such a guilty depression that thoughts I'd never had before about myself, began to dance in my head. It terrified me....Then I got angry...
"There's no doubt your mother was toxic. She hit the wall running!" as one Dr. put it during a hospital meeting months later in an attempt to get answers. Over a 48 hour period she received over 20 doses of 2-4 mg's of the pain medication Hydromorphone AND in addition, was given an increase of a recalled 25 mcg Duragesic brand Fentynal pain patch. "It was a different brand that was recalled" said the Pharmacist who was responsible for dispensing the drugs.
"Are you sure about that?" I asked the pharmacist who was present during our family meeting with the hospital. "Yes" she said, "I know because Duragesic is the only brand we use and it was not one of the ones recalled".
Really...
This from the Health Canada Website issued Feb 14, 2008: Advisory2008-29February 14, 2008For immediate releaseOTTAWA - Health Canada is advising Canadians not to use 25 mcg/hr Duragesic (fentanyl transdermal system) patches sold by Janssen-Ortho Inc. and 25 mcg/hr Ran Fentanyl Transdermal System patches sold by Ranbaxy. Duragesic and Ran Fentanyl Transdermal System 25 mcg/hr patches are being recalled by the manufacturer because they may have a cut along one side of the patch which could result in leaking of the fentanyl gel from the patch. Exposure to fentanyl gel that has leaked from the patch may lead to increased skin absorption and could result in serious, potentially life-threatening adverse events".
In the meeting with the Hospital I was surprised that they admitted my mother was irreversibly toxic until I later found out that "disclosure" is ethically required. The CMPA (Canadian Medical Protection Agency) has a whole section on how to "disclose" when an adverse event occurrs without admitting fault, they call it "Guidelines". https://www.cmpa-acpm.ca/cmpapd04/docs/resource_files/ml_guides/disclosure/introduction/understanding-e.html
Although they "disclosed" this, no acknowledgement of error was ever admitted. "We learn from these things" said one of the Dr's. Seconds later and on the heels of that comment, one of the Directors said "but we just want you to know we followed all procedures". The fact is, that is not true. Delivery of pain medication, better known as "Titration" is the method used by healthcare providers to achieve the right balance of pain medication. It's called "Pain Management". Proper titration happens over several days, even weeks and requires close monitoring.
That comment negated everything that was said prior. It was a waste of a meeting.
How, I ask, does one learn from something when there hasn't been an admission of error? I left with more questions than answers.
My mission: To promote patient safety by providing statistical facts, sharing insights as well as tips on how you can achieve "safe care". Things like, knowing the right questions to ask, understanding the "legal" definitions and terminology, acknowledging the difficulties nurses and healthcare providers face on a daily basis, recognizing that there are sometimes differences in agendas between the "decision makers" and the people who just want to provide the care. Leverage yourself with an educated voice.
My hope is that my documentary will cause a paradigm shift in the way we think about what is acceptable and what is not. The fact that preventable medical errors exists at all proves an acceptance to it. The reality is, we need to reach a ZERO tolerance with respect to preventable medical errors. Preventable means exactly that.
Hospitals need the necessary resources, equipment, checks and balances and most of all, support to the nurses and health care providers so quality of health care to patients in hospitals and acute care facility occurs at the level people expect and deserve.
I should have been able to trust in the care provided by the hospital during my Mother's 2 day stay. Instead I felt alone, isolated, invisible and in utter shock and disbelief that the medical system could fail my mother so miserably. Not one Doctor, not one nurse, NO ONE walking into her hospital room, recognized the signs of toxicity. "Warning signs were missed, judgments were made that were just plain wrong".
Each year, an estimated 10,000 patients die in Canadian hospitals as a result of staff errors, while a further 10,000 die from "non-preventable adverse events," such as hospital infections and unexpected drug complications. Another 20,000, give or take, die of unforeseen or preventable causes while under care outside hospitals. That's an average of more than 100 people -- someone's family and friends -- taken every single day. These staggering figures are extrapolated from data collected in the U.S., Britain and Australia, but are widely accepted as reasonable approximations. In 1999, the U.S. Institute of Medicine estimated that up to 98,000 Americans a year die in hospital due to medical errors, and another million are injured. A 2000 study found that adverse events cause patient harm in 10 per cent of hospital admissions in Britain, amounting to 850,000 times a year.
While my mother's death was inevitable due to the advance stage of her Cancer, could the journey have been any different? I believe so. I can't even fathom the fear one experiences in the face of death, how one reconciles this in their mind, in their heart, in their soul. To subject someone to an additional "ordeal" on top of this is unconscionable to me.
My mom knew something was wrong during those two days in the hospital, she knew she wasn't "right". At one point her heart rate reached 160, in sheer terror, in absolute confusion.
The absence of this adverse event would most definitely have improved the quality of her last days and just may have extended her life.
For five weeks, my sister and I took shifts so that around the clock, every day, every hour, every minute was spent at her bedside until the day she died. To my mama...I love you, I miss you terribly, rest in peace...
UPDATE:
Since the writing of this blog I've written letters to both the Patient Care Quality Office and the Review Board. I received a response back from the Patient Care Quality Office which prompted me to take it to the next level, the Review Board. I am awaiting their response. A copy of the letter can be viewed on my blog.
One final thing. When you see a dragonfly, smile. It's my mom's way of thanking you for passing this blog on to others. To all of you who have a lost a loved one, my heart goes out to you. My hope is that this inspires truth and hope, even when is seems all hope is gone.
Thanks Go To:
My heartfelt thanks go out to Dr. McGinnis, the only one who heard my cries for help.
To Dr. Sheehan and all the healthcare providers at the Vancouver Cancer Clinic, I thank you for the care you gave my mother.
To the Port Moody Hospice, where my mother spent her remaining days. My mother could not be saved but you saved our family with your compassion and care, it gave us peace in knowing her final days were spent in love and in peace.
To my employer for giving me the freedom to put my mother first.
To Harvinder, thank-you for your compassion you showed toward my mother.
To Angie in 'Admitting' at the Vancouver Cancer Clinic, thank you for expediting the first appointment with the Oncologist.
To Dr. Romayne Gallagher, I'm so grateful to have found you! My hope is that we can work together on future projects, I volunteer my time to you. It was through you that I learned so much about "Opioid Induced Neurotoxicity". The understanding of what my mother experienced made things "make sense" during a very confusing time. You exemplify what other Doctors should aspire to.
To Lisa in Victoria - you know who you are, thank you for sharing your information with me...it was fate we crossed paths..
To Patty Russell - I will never forget you, thank you for caring about and for my mother.
To the Volunteer drivers, thank you for providing transportation for my mother and me during her Radiation treatments, your volunteer efforts help so many...
To Elena and my whole family, thank-you for all your support and love.
To Sandy, my sister, my angel, I love you.
More to come...I hope to hear from you...God Bless...
