After her abdominal operation last summer, the patient's hip started to ache. The symptom of a painful joint was hardly a surprise - she was a senior citizen - but the cause of it, picked up on an X-ray, was: a pair of four-inch forceps floating in her abdominal cavity.
What happened next is equally astonishing: The surgeon who performed the gynecological procedure in a Winnipeg operating room apologized. Hospital staff followed up with their own apology, telling the patient if she required any help, it was available.
It's all part of a new approach by Winnipeg officials, hailed as the first of its type in Canada: apologizing to patients when a mistake is made and offering compensation where appropriate.
"People are slowly getting used to the idea that there are lots of preventable injuries and preventable deaths," said Rob Robson, chief patient safety officer for the Winnipeg Regional Health Authority. "And we need to get off our butts and do something about it."
Mistakes in medicine have long been seen as something best buried with the patient. In the past, the tendency to defend and deny has been favoured by malpractice lawyers and insurers, who feared full disclosure would unleash a torrent of lawsuits.
That way of thinking is slowly beginning to change due to a patient safety movement, boosted by research - and experience in the United States, showing that patients are actually less likely to sue if they are provided with full disclosure and an apology.
British Columbia, Saskatchewan, Manitoba and, most recently, Alberta have passed legislation to ensure that any apology offered to patients cannot be used against the health profession in a legal action. Ontario and Nova Scotia have also introduced apology legislation, while the remaining provinces have not.
Underlying these changes are figures published in the Canadian Medical Association Journal in 2004, showing that as many as 23,750 hospital patients died avoidable deaths in 2000.
That same study found one in 13 adult medical and surgical patients admitted to acute-care hospitals suffered at least one adverse event.
By taking a principled approach of quickly disclosing medical errors and apologizing to patients, health officials hope to restore dignity in their dealings with them. In the United States, where there are apology laws in at least 34 states, there has been a resulting reduction in malpractice claims.
For example, at the University of Michigan Health System in Ann Arbor, claims and lawsuits have dropped since it began disclosing adverse events in the spring of 2002. In August, 2001, the system had 262 claims, with more than half in litigation. By August, 2008, it had 61 claims and only 13 in litigation, according to Richard Boothman, the medical centre's chief risk officer.
"Hospitals that stonewall their patients and at the first sign of trouble go underground and refuse to talk to them end up leaving those patients with few alternatives in this country but to hire a lawyer to get answers," Mr. Boothman said. "What our experience has shown is that if you give patients a chance to understand, they don't get misconceptions about what happened."
He pointed to a case of one lung cancer patient who was misdiagnosed as having a recurrence; her oncologist thought she'd be dead in six months. One year later, when she was still alive, the pathologist looked at the slides and determined that the tissue was not malignant but simply inflamed. She ended up settling her case for $60,000 (U.S.). "The adversarial nature has almost dissolved," Mr. Boothman said. "We ought to pay what we owe, not what we can get away with."
Timothy McDonald, chief safety and risk officer for the University of Illinois Medical Center, said mistakes are frequently systemic - it's rarely one person or one action that has caused the harm.
"We shame, we blame, we fire, we do all those things to those people and it's almost always a systems issue," Dr. McDonald said. "... They need to know they're not a bad person, they need to know that medicine is a dangerous business and they need to know the institution is going to support them unless they do something that's reckless."
John Cowell, chief executive officer of the Health Quality Council of Alberta, was the first to have a formal framework for disclosing harm to patients before the province enacted its apology law in November.
"When you are open and honest, the chance of being sued drops way off," Dr. Cowell said. "... If you start getting into hiding, non-disclosing and covering up, boy I tell you, that just causes people to go very crazy and they will just relentlessly pursue it."
In the Winnipeg case, Dr. Robson said, there was a transition from one operating room staff to another, with the second team thinking the sponge and instrument count was complete when it wasn't. The forceps, which have a blunt end, migrated and caused pain to the patient's hip.
"We're no different than anyone else," Dr. Robson said. "It's quite common."
The patient, who declined to be interviewed, had to undergo a second operation to remove the forceps. The hospital helped her manage her appointments and set up home care and physiotherapy. The surgeon, meanwhile, offered "to transfer the care to somebody else," Dr. Robson said. "And she said, 'No, 'I trust you, you did a good job in my surgery.' "
ERRORS IN MEDICINE
Oops
The pelvic X-ray of 69-year-old Australian Pat Skinner shows the surgical scissors that doctors at a Sydney hospital had left inside her during a colon operation in 2002. Ms. Skinner had felt 18 months of abdominal pain before insisting on the X-ray that revealed the mistake. In Winnipeg, officials are trying a new policy of apologies and compensation when similar mishaps occur in its hospitals.
