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Surgery Incidents in which a foreign object is left behind in a surgical cavity affect about 1 in 3,000 patients in Canadian hospitals. Dr. Jennifer Zelmer, CIHI's vice-rresident of Research and Analysis says tracking medical errors and adverse incidents is important in learning how to prevent them.

One in 10 receives wrong meds in hospital

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Date: Tue. Aug. 14 2007 9:18 PM ET

A new analysis about the chances of being injured or harmed during treatment in Canadian hospitals finds that some errors occur with disturbing frequency.

According to the report by the Canadian Institute for Health Information (CIHI), the chances of patients receiving the wrong medication or wrong dose was about 1 in 10 in 2005.

The chances of an adult contracting an infection while in an acute care hospital are about the same: 1 in 10, while the chances of a child contracting an infection while in hospital are about 1 in 12.

Incidents in which a foreign object is left behind in a surgical cavity are less common, affecting about 1 in 3,000 patients in Canadian hospitals (outside of Quebec and parts of Manitoba). Yet that still adds up to more than 200 incidents per year between 2003-2004 and 2005-2006.

Previous studies show that obese patients are at higher risk of having a foreign object left behind after surgery, though the reasons aren't clear.

Other higher risk groups include: patients who undergo emergency operations, those who have an unexpected change in operation or those who have a change in nursing or surgical staff during a procedure.

"The consequences of leaving a sponge or other foreign object in after surgery can be significant, but experts suggest that targeted strategies can reduce the risk," says Dr. Indra Pulcins, CIHI's director of Health Reports and Analysis.

Those strategies include following a practice of sponge and instrument counts, as well as vigilant inspection of body cavities when the surgery is complete.

One of 21 mothers giving birth by vaginal delivery in hospital experience obstetrical traumas, such as lacerations of the cervix, vaginal wall, or injury to the bladder or urethra. Between April 2003 and March 2006, there were more than 9,100 reported obstetric traumas in Canadian hospitals, outside of Quebec each year.

One in 141 babies born in hospitals outside of Quebec experienced birth trauma, such as injuries to the scalp, skull fractures, or injuries to nervous systems. This represents more than 1,700 cases yearly.

Previous research suggests that risk factors for trauma during birth include newborns weighing more than 4 kg, long labour, the need to use instruments during delivery and a woman's position during birth.

CIHI's analysis found that 3.6 out of every 1,000 patients in Canadian hospitals (outside Quebec and parts of Manitoba) experience a pulmonary embolism while in hospital. An embolism occurs when a blood clot or globule of tissue travels through the veins and into the lung, and can occur when patients are bed-ridden or sedentary for long periods.

Dr. Jennifer Zelmer, CIHI's vice-president of Research and Analysis says tracking medical errors and adverse incidents is important in learning how to prevent them.

"While we do not know how to prevent all adverse events, tracking how often they occur and understanding the factors that contribute to them is an important step in improving patient safety," says Zelmer.

Experts have suggested a number of strategies to reduce the risk or errors and patient harm, including automated drug alerts and medication reconciliation -- the process designed to prevent medication errors at patient transition points.

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Lynne
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I am in BC and, in the past couple of years, I had one friend die while under overnight observation in the hospital for a sore throat. Another friend went in for a common surgery and came out with a massive infection and huge hernia, which took nearly a year to treat. Another friend went into emerg. for treatment of a relatively minor wound, and soon developed strep infection. I myself had a "simple" knee surgery which left me still crippled, seven years post surgery. It seems that few in the medical profession care about fixing patients anymore -- it's all about a paycheque for most. Our medical services system needs desperately to be overhauled.


p gaudet
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My husband had emergency surgery after a botched colonscopy in August 06 and in the pre-op was identified as having had a heart attack. In January he was diagnosed with Stage iv lung cancer as a result of x-rays taken in emerg and in April 07 had another heart attack. You hear so much about the failing health care system in Canada but we have had nothing the best of care since entering emgergency room at a Toronto hospital. The doctors have taken the time to return calls and spent generous amounts of time explaining results of tests and options available to us. We are very happy with the care that my husband has received. Nothing but the highest level of professionalism from all of the drs and nurses that we have encountered.


Christopher Pryde
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Errors made by those working within our medical system almost certainly contributed to my father's health problems. The nurses were ignorant or oblivious to his needs. The doctors were disinterested and self-absorbed. In the end one doctor removed a drug that another had prescribed. I will attend his interment on Sunday.

The system is broken at its foundation. We need to rebuild it beginning with the training of our current medical students.


Andrew H
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Maybe it would help to review the demands placed on health-care workers when we are assessing why errors are made??
Maybe they are overworked and under-paid??
For example, when you go see your family doctor they get paid about $30 for the visit. This is regardless of the number of problems you are being seen for. Roughly $10 of that $30 goes to overhead expenses (paying staff, renting office space, supplies etc) roughly another $10 goes to taxes paid to the government (even though most family doctors have no pension plan, and no health insurance plan, and no vacation pay).

So for about $10 your family doctor does their best to provide you with the best care possible.

Every Canadian doctor would love an electronic office. However, an electronic medical system can cost thousands per month to run and is usually only feasible for large groups, hospital clinics, or when grants are given to fund them.

On a positive note, Ontario recently started a program where you can have all of your medications reviewed by your pharmacist. This is paid for by the province. This is in an attempt to reduce medication errors and interactions.

There is also a huge shortage of nurses in Canada. Many nurses are pushed into taking extra shifts and working overtime to fill in the gaps. They are way overworked and underpaid.

If you are concerned about the quality of the medical care you receive then you should take the time to write your provincial and federal MPs and your provincial and federal ministers of health and demand that your taxes are used more responsibly by adequately funding the Canadian health-care system.

Health-care workers aren't malicious or uncaring or inattentive people. They have devoted their lives to helping others and sadly lack the support they need from the government and lack the respect and understanding they need from their patients.


David Wildeboer
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I'll wade in on the other side. None of us try to make mistakes but we're human. With the pressures today and long hours and waits due to inadequate funding (time for a mix of private and public funding like most other countries), things happen. As physicians, as well as all other health professionals, we try to do our best but mistakes still happen. Most are minor and have minimal if any harmful effect (of course, all the "bad" ones get disseminated) and apologies are usually made.

As for electronic records, I'm a family doc in Alberta where at least 60% of physicians have an EMR. However, these systems are not user friendly as most are designed by people with little experience in the health field. Or, in the case of the system we have, was initially designed by physicians but then taken over by programmers making it less user friendly and less functional. All these systems require lots of extra programming to be province and region specific so there are more places to break down.

As for the hospitals, there are no systems that I know of with a Canadian specific EMR. Most of the products are American and as such are designed to prevent lawsuits by multiple, multiple layers of redundancy and checks and are therefore clunky and unusable. If someone out there wants to start from scratch and design and program something that works for Canada, you'll have lots of happy and grateful health professionals.


John B
said
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Isn't it true that the fourth leading cause of death is medical errors!

Thank god airline pilots aren't forgiven as easy!


Karen
said
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Many of the drug problems can be eliminated by using e-prescribing.

Ian Whitecross
said
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The worst part of this fiasco is that once you find out that the prescription was wrong you aren't reimbursed for the medication they had you on. I would like to see the doctor pay you back for the error.


Randy S
said
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I would have to agree that there are some serious flaws in our medical profession. My father had quad bypass almost 2 years ago ... and that did go extremely well. HOWEVER, there is a battery of different medications that they give bypass patients post op, in which case some assumptions are made. He received and was told to take all of these pills, one of which was to lower blood pressure (here is the assumption) because people who have bypasses must have hight blood pressure. WRONG, he did not and never had high blood pressure and almost died 2 times in the immediate week that followed the operation as his heart rate fell to and extremely dadngerous low level. This was due to lack of communication between the hospital and the family doctor.


Brian S
said
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I completely agree that the old-fashioned clipboard approach by the Canadian medical profession is shameful. My wife just came back from advanced cancer treatment in Japan where every doctor she met directly inputted her information into a computer so that complete and accurate information would be available for the next consultation.

Here in Canada, her doctors repeatedly have had to scramble to look for information because it had not yet been transcribed onto the out-of-date files at the hospital.

When will Canada catch up to the rest of the advanced world?


Vince M
said
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Having some experience in this area I can tell you the health profession, and doctors in particular, seem to be the worst at adopting information technology. It is rediculous that we are still writing things down on a clipboard or in a file that can easily get overlooked and cause the wrong medication (or a repeat of medication) to be given. In a time of widespread use of computer technology why is the medical community rejecting readily-available electronic patient records?


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