In May of last year, the Canadian Medical Association Journal published a blockbuster study, one that showed that between 9,250 and 23,750 hospital patients die each year due to "adverse events" -- the polite term for medical errors.
That nearly 24,000 Canadians die annually of largely preventable causes is truly shocking. But more shocking still has been the response of policy-makers and administrators.
"A few things have happened but, honestly, I expected more," Ross Baker, a professor of health-policy management at the University of Toronto and co-author of the study, said in his understated way.
Alberta and Saskatchewan, the two provinces that are, by far, leading the way in health reform, have started developing reporting systems. So have some hospitals in Ontario and Quebec.
But there has been no concerted national effort to tackle this scourge. The Canadian Patient Safety Institute, created in December of 2003, is barely up and running, has a paltry budget and no legislative muscle.
The regulator ultimately responsible for patient safety, Health Canada, is, as usual, "monitoring the situation."
So it remains that 7.5 per cent of patients admitted to a Canadian hospital -- one in 13 -- suffers harm as a result of their care.
Dr. Baker and his co-author, Peter Norton, head of the department of family medicine at the University of Calgary, made clear that their numbers were conservative, and the tip of the iceberg. (Researchers looked at 3,745 randomly selected charts from 20 hospitals in five provinces. The range is broad because the sample size was relatively small. But much hospital record-keeping is inadequate, so the problem may well be larger.)
Doctors Baker and Norton looked only at deaths, not at the extended hospital stays, the disabling injuries, the treatment costs and the ripple effects on providing care to others.
A few weeks after the Baker-Norton study, the Canadian Institute for Health Information released complementary data showing that treating people felled by medical errors eats up more than 1.1 million hospital days and adds a staggering $750-million to the country's health-care bill each year.
The CIHI report also provided graphic details on the woes befalling patients. For example:
One in nine adults contracts an infection while in hospital, ranging from pneumonia to SARS;
One in nine patients receives the wrong medication, or the wrong dose;
One in 20 women suffers severe tearing during childbirth; one in every 81 babies born vaginally suffers trauma, emerging with injuries such as a broken shoulder;
One in every 299 patients receiving a blood transfusion will have a reaction;
One in every 1,124 adults over age 65 suffers a broken hip during a hospital stay;
One in every 6,667 surgery patients will have a foreign object left behind in his or her body.
To be fair, not all adverse events are preventable. But many, maybe even most, are avoidable. Proven means of reducing every one of those categories of errors already exist.
But the first step is admitting there is a problem.
Hospital administrators, health policy-makers and their political bosses have taken a head-in-the-sand approach to this issue. There is a widespread view that discussing adverse events openly will invite legal action and cost more money than trying to patch up mistakes.
The thorny issue of legal liability -- which has created an absurd situation where many doctors and nurses no longer even talk of medical errors and how they can be avoided, for fear they will be implicated in lawsuits -- has to be dealt with by legislators so we don't have a situation where malpractice suits paralyze the system and undermine care, as in the U.S.
But the reality is that very few medical errors are the result of negligence on the part of an individual health-care professional. Rather, they are systems failures: inadequate cleaning of rooms, lack of hand-washing by doctors and nurses; poor charting; understaffing; absence of clear procedural rules, and so on.
Fixing these problems will not only prevent deaths, it will improve care for everyone, and free up resources. But the only way we are going to fix these problems is if there is good reporting and systematic follow-up.
That's going to take money and leadership. And while those are both in short supply in the health system, this is one area where investment will pay off big, in lives and on the bottom line.
More than 2.5 million Canadians are admitted to hospital each year. Every one of these patients, their family members, and their caregivers should be concerned by this issue.
One chance in 13 of suffering harm in hospital is not good odds; 24,000 adverse-events deaths is a disgrace. It is hard to imagine anything that undermines public confidence in the health-care system more than the on-going silence and indifference to this pressing issue.