Canadian Insurance News

Tom Blackwell | January 16, 2015 | Last Updated: Jan 19 5:16 PM ET
More from Tom Blackwell | @tomblackwellNP

As Helen Church woke up one morning just before Christmas 2012, the pain that had been building for weeks behind her right eye reached an excruciating climax.

Screaming in agony, she ran around her east-end Toronto apartment before finally managing to call 911 and passing out.

For the second time in short succession, she had fallen victim to health care gone badly awry.

Just two years earlier, Ms. Church went to a nearby hospital to have an ovary removed as treatment for a painful cyst. She left hours later with the ovary still in place — and a piece of mesh embedded in her abdomen to repair a non-existent hernia.

Then, months later, a specialist replaced an artificial, cataract-correcting lens that he said had started to wear. The result: That eye was now blind and growing increasingly painful.

The ophthalmologist, another specialist told her later, had implanted the lens in the wrong position, obscuring her sight and puncturing a duct, causing a slow bleed and massive pressure.

“There was so much blood in there, it blew the eyeball out of my head. It was hanging on my cheek,” said Ms. Church, a razor-sharp 83-year-old. “The blood was just dripping everywhere … I was hysterical, the pain was so bad.”

Both incidents point to dangerous breakdowns in the Canadian health-care system. But don’t expect to find any public record of either apparent blunder — or of thousands of similarly harmful and sometimes deadly mistakes that occur in facilities across the country each year.

Most instances of the system hurting rather than healing patients, in fact, are not even reported by staff internally, a National Post investigation has documented.

Research suggests that about 70,000 patients a year experience preventable, serious injury as a result of treatments. More shocking, a landmark study published a decade ago estimated that as many as 23,000 Canadian adults die annually because of preventable “adverse events” in acute-care hospitals alone.
The rate of errors may be even higher today, some evidence suggests, despite the millions of dollars spent on much-touted patient-safety efforts.

Yet a tiny fraction of those cases are publicly acknowledged and usually only in the form of antiseptic statistics. For most serious treatment gaffes, not even the sparsest of details is revealed, making the vast problem all but invisible.

The Post has also learned there is no routine, public documentation of one common source of health-care harm — malfunctioning medical devices linked to dozens of deaths and hundreds of serious injuries every year.

“Learnings from these things, even when a good investigation is done, are going into black holes,” said Darrell Horn, a “critical-incident” investigator who spent several years with the Winnipeg Region Health Authority. “They’ve created this perfect, invisible box to put everything in.”

Manitoba is actually a rare exception to the opaqueness that shrouds medical error in Canada; single-line descriptions the province has released for the last three years offer at least a snapshot of what calamities can befall patients.
Among the 100 cases reported in the three months ending Sept. 30, 2013, was that of a new mother who had a heart attack after staff inadvertently gave her a blood-pressure-increasing medication, instead of a nausea antidote following a caesarean section.

Another patient, known to be at risk for blood clots, suffered a fatal cardiac arrest when staff neglected to provide preventive treatment after surgery.
A woman needed a second operation after an X-ray revealed a screw from a broken clamp had been left inside her during a C-section.

And, without further explanation, one patient “underwent unnecessary open-lung biopsy.”

For the rest of the country, such cases occur in a vacuum, most not reported at all and virtually none described with any kind of narrative.

In fact, legislation in most provinces bars information on adverse events being released to malpractice plaintiffs or publicly divulged under freedom-of-information acts. The laws are designed — with limited success — to encourage internal reporting of mistakes.

A health-care culture still straitjacketed by an old-fashioned hierarchy, fear of legal action and a focus on punishment rather than learning from mistakes also keeps missteps bottled up, say health workers and safety experts.

A nurse at an Ontario hospital, who asked not to be identified for fear of repercussions, said she works with two surgeons whose skills are so lacking, “I wouldn’t even want them to touch my dog.”

She filed an anonymous complaint against one several years ago, but little changed. Now, she stays mum about problems ranging from high rates of post-op infections to surgeries frequently needing re-dos.

“We do turn a blind eye and walk away,” the nurse admitted. “There is a lot of lying, there’s a lot of cover-up, which turns my stomach.”

By contrast, preventable injury and deaths in many other arenas — from homicides to industrial accidents and road crashes — are routinely divulged by police or other authorities.

There is a lot of lying, there’s a lot of cover-up, which turns my stomach

The starkest counterpoint to health care’s lack of transparency around error, however, is offered by the aviation industry.

On the way to dramatically improving the safety of flying, the sector has become conspicuously open about its mishaps. Canada’s Transportation Safety Board, for instance, posts details online of current investigations into everything from actual crashes to ground vehicles inadvertently driving across airport runways.
The constant, transparent exchange of safety information not only helps curb accidents, but enhances passengers’ confidence in the industry, says John Pottinger, an aviation-safety consultant and former Transport Canada official.
“Where the public even thinks it is being deceived or doesn’t have the whole story, then right away we get suspicious,” he said.

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