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.
Source:
A
damning report on the auto insurance industry in Ontario was released
yesterday by two York University professors in Toronto, on behalf of the
Ontario Trial Lawyers Association. The report suggests insurers were
allowed to overcharge insurance premiums dating back to 2001, 
A
car accident 18 years ago led to a $1.5 million settlement for the
victim, whose life has never been the same. However, the Nova Scotia
government is taking legal action to claim some of the money paid out to
the family.
