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Patient group aims to lift veil on medical errors

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Canada AM: Donna Davis, Patients for Patients Safety Canada
The co-chair of a new group calling for more attention to in-hospital medical errors, which kill about 24,000 Canadians, explains why patients say they struggle getting hospital staff to admit the mistakes.

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Date: Wed. May. 5 2010 6:59 PM ET

Each year, medical errors kill almost 24,000 Canadians, yet many patients say they struggle getting hospital staff to admit the mistakes. That why they've formed a new group calling for that to change.

The group, called Patients for Patient Safety Canada, launches Wednesday. The founders say the goal is to give patients a voice in their care, to help health care providers learn from mistakes, and to work together to make improvements that will make health care safer in Canada.

Maryann Murray worked with the group after spending most of the last decade trying to find out why her daughter Martha died of an easily-preventable prescription error.

Martha suffered from a heart rhythm disturbance called cardiac arrhythmia and had been prescribed a medication that someone with her heart condition should never have been allowed to take.

"In fact, the drug manufacturer said it was contraindicated for her condition, and exactly what they said might happen did happen. Her heart stopped," her mother Maryanne told CTV News.

"She went to bed one night and the next morning her father found her dead beside her bed. It was that sudden."

Murray says along with the pain of losing her daughter came the realization that the prescribing error was never acknowledged.

"Our daughter died and instantly it was called natural and they tried to close the case. Nobody wanted to investigate and find out why a seemingly healthy 22-year-old was dead."

Donna Davis, another of the group's members, lost her 19-year-old son Vance eight years ago following a car accident. She says it wasn't the accident hat killed him, it was the lack of communication among hospital staff that led to her son's death.

"They did not recognize Vance's head injury being as serious as it was," she recalls.

"He did not receive the care in hospital that would have given him the best chance of surviving those injuries."

Davis says she helped form Patients for Patient Safety Canada because she believed the collective voice of patients could help to improve things in the health system.

"If the patients were given a voice, and could help and work with health care providers to make improvement, then situations like Vance's… could be prevented," she told Canada AM Wednesday, ahead of the group's official launch at North York General Hospital.

Davis says for her, one of the hardest parts of her son's death was getting the hospital to admit its mistakes.

"The culture then was ‘Don't talk about it,' and patients and families need so much more than that," she says.

"We need the acknowledgement that something terrible had happened, that something had gone wrong. We need the acceptance of responsibility on the part of the health organization or the health provider that things went wrong and we need them to apologize to say we are sorry and this is what we are going to do to make things different. This is how we are going to improve the system and that is really what we want."

Davis says part of the goal of Patients for Patient Safety Canada is to urge hospitals to admit and be open about their mistakes.

Dr. Wendy Levenson, a professor of medicine at the University of Toronto who has studied the problem of medical errors, says she believes that doctors are more willing than ever to acknowledge mistakes and learn from them.

She notes for example that the Canadian Patient Safety Institute, established by Health Canada, has set out national guidelines for the disclosure of adverse events. Still, she says, there is room for improvement and she welcomes the new patient-focused group.

"I think it is wonderful that patients are actively seeing this as an issue and looking for an opportunity to work with health professionals, because I think if patients encourage open disclosure and discussion and recognize that they can work with the team to help improve care… they can be part of a learning opportunity and a learning process with us. And that is very important," she says.

She notes that there's often friction between two competing sentiments when it comes to discussing medical errors: doctors' fear of being sued, and patients' desire for more information.

Levinson says what patients and families who have experienced a medical error often want is simply an explanation of why it happened, as well as an apology and assurance that the health care field will learn from their mistakes and share the learning.

For Murray and Davis, they say their fight for answers has never been about money. It's about getting answers that took years to get, and it's about the pain they want to prevent others from suffering.

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