Mortality Due to Medical Misadventures
- Canada ranks 7th among 15 peer countries, earning a “B.”
- Seven per cent of all patients admitted to acute care hospitals in Canada (or about 158,000 Canadians a year) will suffer a medical misadventure. Close to 60,000 of these cases are preventable. About 150 patients die a year as a result of adverse medical events.
- Information about adverse events and near misses provides greater insight into how to strengthen patient safety than data on morbidity and mortality provide.
Putting medical misadventures into context
Canadians place great trust in health-care organizations and are generally satisfied with the health care they receive. In 2005, 85 per cent of Canadians who received health care were “very” or “somewhat satisfied” with the services they received.1 Additionally, in a recent Canadian Institute for Health Information survey of patients accessing primary care, more than three-quarters (76 per cent) reported that the quality of the primary health care they received in the past 12 months was either “excellent” or “very good.”
However, a growing body of evidence over the past decade has demonstrated that misadventures during surgical and other medical care are common around the world, and Canada is no exception. These misadventures are tragic for individuals and costly for society, as they can result in disability, death, or prolonged hospital stays. A Canadian study estimated that about 7 per cent of adults seeking acute care in Canada experience a misadventure; from these cases, close to 60,000 are potentially preventable.2 The latest OECD figures show that about 150 deaths are caused by misadventures during medical care each year in Canada.3
Examples of misadventures (or adverse events) include an unintentional cut, gauze accidentally left in a body during surgery, the failure of sterile precautions, or the failure to administer a correct dosage of drugs or radiation. Many of these misadventures have been listed by the National Quality Forum in the United States as “serious reportable events” that should never happen to a patient (“never events”).4 All misadventures are considered unintended, but not all of them are considered preventable. Preventable or avoidable adverse events result from the failure of individuals or health-care systems—or often both—to follow recognized, evidence-based best practices or guidelines.
Why include a patient safety indicator?
Confidence in the safety and efficacy of the health-care system is critical. Efforts to improve patient safety have emerged in the last decade at local, national, and international levels. Safe practices help restore a patient’s health promptly, providing tremendous social and economic value to any nation.
Besides these obvious benefits, there is evidence that high-quality health services can help control spending by reducing costly complications and preventing unnecessary hospitalizations. U.S. researchers identified 18 potentially preventable adverse events and complications of care that may lead to “a total of 2.4 million extra days of hospitalization, $9.3 billion in excess charges, and 32,591 deaths in the United States annually.”5 More recently in Europe, it was estimated that total direct medical costs of preventable adverse events in the Netherlands accounted for 1 per cent of the expenses of the national health-care budget.6 Clearly, safer health-care services help health systems spend their limited health-care dollars more wisely.
How does Canada rank among its peers?
Canada is a middle-of-the-pack performer. Canada ranks 7th among 15 peer countries, earning a “B” on the report card for medical misadventures. In 2007, the number of deaths due to misadventures during medical care worked out to 0.4 per 100,000 people (or 4 deaths per million) in Canada. The top performer, Denmark, had 0.1 per 100,000 people (or 1 death per million), while Australia ranked last, at 1 death per 100,000 people (or 10 deaths per million).
Are fewer Canadians dying of medical misadventures than in the past?
The number of reported Canadian deaths from misadventures during surgical and other medical care has increased since the early 1980s. In 1980, it was 0.1 per 100,000 people (or 1 death per million people). This number has since grown fourfold to 0.4 per 100,000 people (or 4 deaths per million people). This upward trend could partially be explained by a higher reporting of cases resulting from increased awareness of the importance of reporting and from the availability of better tracking systems. Interestingly, although the U.S. has seen more deaths reported due to misadventures per 100,000 population than Canada has, the gap between Canada and the U.S. is closing. The number of these reported deaths is decreasing in the U.S. and increasing in Canada.
What are the challenges of measuring patient safety and quality?
Measuring patient safety as an indicator of the quality of health care presents some challenges.7 Although morbidity and mortality data are useful, these indicators do not capture the majority of adverse events and near misses (unplanned events or conditions that have the potential to result in injury, illness, or damage). Reporting near misses provides greater insight into how to strengthen patient safety. Unfortunately, near misses and many adverse events are not properly captured by voluntary or mandatory incident reporting systems.
So-called “never events” (defined by the National Quality Forum as errors in medical care that are clearly identifiable, preventable, and serious in their consequence to patients)8 should be tracked and reported by all health-care organizations. Legislation and policies mandating the reporting of these events can enhance patient safety. In the U.S., some states have adopted “never events” legislation or policies, and the Centers for Medicaid and Medicare Services has identified a list of never events for which it will not pay. Other insurance companies are also adopting these practices.
Besides focusing on quality control from an organizational level, health-care systems need to foster open and non-punitive environments that encourage reporting. These environments are fundamental to establishing safer health-care practices.9,10 Countries with no-fault systems of indemnification for medical malpractice that encourage the reporting of medical or surgical misadventures (e.g., Sweden and New Zealand) are more likely to report adverse events than countries with tort liability systems (e.g., U.S., U.K., and Canada).11
Attempts have been made to strengthen patient safety and risk management in Canada, but significant work is still needed to improve measurement and monitoring systems. A recent report in Alberta looking at infection prevention and control and sterilization practices found that “lack of a widespread patient safety culture and alignment of organizational structures to support patient safety” was partially responsible for infection control problems in Alberta.12
As Canada strengthens its patient-safety culture and improves its health-care information management (by using electronic health records and a pan-Canadian reporting and learning system), it will be possible to better detect safety issues. It will also be possible to react to safety issues in a more timely manner, and to disseminate learnings more effectively.
What has Canada done to address patient safety and the quality of health care?
The 2003 federal budget announced the creation of the Canadian Patient Safety Institute in response to the 2003 First Ministers’ Accord on Health Care Renewal. This institute’s mandate is to foster collaboration between governments and stakeholders through the development of patient safety initiatives and research. It has identified patient safety targets and is helping to coordinate efforts to make health-care services safer in Canada. (For more information on these initiatives, visit the Canadian Patient Safety Institute website.)
Accreditation Canada has also made significant contributions in this area. Since 2005, it has introduced 31 required organizational practices—evidence-based practices that if not in place within Canadian health-care organizations there is the potential for patient harm. Additionally, a number of provincial health-quality councils have been created to work with local delivery systems (e.g., the Ontario Health Quality Council, the Health Quality Council of Alberta, Saskatchewan’s Health Quality Council, and the New Brunswick Health Council).
2 G. Ross Baker et al., “The Canadian Adverse Events Study: The Incidence of Adverse Events Among Hospital Patients in Canada.” Canadian Medical Association Journal 170, 11 (2004), pp. 1678–1686.
3 OECD database, 2004 is the latest year available.
5 C. Zhan and M.R. Miller, “Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization,” Journal of the American Medical Association 290, 14 (2003), pp. 1868–1874
6 Lilian H.F. Hoonhout et al., “Direct Medical Costs of Adverse Events in Dutch Hospitals,” BMC Health Services Research, February 2009, [online, cited September 14, 2009].
7 Agency for Healthcare Research and Quality, Making Health Care Safer: A Critical Analysis of Patient Safety Practices (Summary) (Rockville, MD: Author, July 2001), [online, cited August 7, 2009]. www.ahrq.gov/clinic/ptsafety/summary.htm; and M.A. Gardam et al., “Healthcare-Associated Infections as Patient Safety Indicators,” Healthcare Papers 9, 3 (2009), pp. 8–24.
8 Centers for Medicare and Medicaid Services, Eliminating Serious, Preventable, and Costly Medical Errors—Never Events, press release, May 18, 2006, [online, cited September 13, 2009].
10 A. Hutchinson et al, “Trends in Healthcare Incident Reporting and Relationship to Safety and Quality Data in Acute Hospitals: Results from the National Reporting and Learning Systems,” Quality and Safety in Healthcare 2009, 18:5-10 (2009).
11 The Conference Board of Canada, Liability Risks in Interdisciplinary Care: Thinking Outside the Box (Ottawa: Author, April 2007).
12 Health Quality Council of Alberta, Review of the Infection Prevention and Control and CSR Sterilization Issues in East Central Health Region (Calgary: Author, July 2007), [online, cited August 7, 2009].