December 4, 2013 Sections
Winnipeg Free Press - PRINT EDITION
IN March, 10-year-old Ashuza Halisi died at the Maples Surgical Centre in Winnipeg, likely as a result of an abdominal infection after her small bowel was cut accidentally during surgery to repair an umbilical hernia.
Her father, Willy, was adamant. "I do not think of it as an accident," he told the Free Press. "I see it as a mistake."
After the Error is a compelling collection of 16 case studies from across Canada, including one from Manitoba (though not the Halisi case, which is too recent).
It recounts the experiences of individuals and their families who have been through a similar ordeal and discusses the projects they have undertaken to prevent others from having it happen to them.
Authors Susan McIver and Robin Wyndham are both well versed in Canadian health care. McIver holds a PhD in entomology and microbiology; she was a medical professor at University of Toronto and a department chairwoman at the University of Guelph and served as a B.C. coroner. Wyndham was a registered nurse for 34 years at Vancouver General.
McIver has written previously about this subject in Medical Nightmares: The Human Face of Errors, published in 2001. It received criticism in some quarters due to its reliance on American statistics.
No such argument can be made here, and the authors do an admirable job in presenting their evidence. They report that 40,000 to 43,000 Canadians die annually due to medical errors. To place that number in perspective, cancer deaths in 2012 were expected to be 75,700.
The stories are alarming. One documents the case of Mimi Raglan of Winnipeg, who "had concerns about the attitude of nursing staff and patient-care managers, limited physician attendance, infections and pain control" in the care of her mother, Frances. While her mother was hospitalized, Mimi was consistently denied access to her ailing mother's health-care record.
It was only after her mother died after a fall at the Riverview Health Centre in 2001 that Mimi was given a copy of the chart. She discovered a series of errors including the administration of medication that suppressed Frances' immune system and contributed to her death from pneumonia.
McIver and Wyndham also document the case of Vanessa Young of Oakville, Ont., who was 15 in 2000 when was prescribed cisapride, a drug used to relieve gastrointestinal distress. Vanessa died as a result of cardiac arrest, due to an abnormal heart rhythm that had been identified as a side-effect of the drug cisapride.
What Vanessa's family didn't know at the time of her death was the pharmaceutical company that created the drug had been aware of this issue since 1992 but continued to market cisapride. At the inquest that followed Vanessa's death, it was noted that "prescription drugs ... are one of Canada's most serious and under-reported causes of health problems."
Then there is the case of retired Montreal physician Jacques Besson. He entered hospital in 2003 for what should have been routine surgery for a herniated disk. Instead, he spent the next year fighting a series of bacterial infections including the "superbug" methicillin resistant Staph aureus (MRSA).
Besson survived, but out of the close to 250,000 hospital-acquired infections that occur each year, between 8,000 and 12,000 Canadians die. The majority of these infections are preventable and can be circumvented by one simple intervention: good hand-washing.
One would think that in our increasingly litigious society that people would be seeking redress through the legal system for negligence. This is far from the truth.
Two consistent themes become apparent in McIver and Wyndham's case studies. The first is that when these cases do end up in court, people are most interested in knowing what happened, why it happened and what can be done so that it will not happen again.
Second, victims need an admission that a mistake was made along with an apology: a sincere acknowledgment that the perpetrators accept the blame for what happened.
To avoid expensive legal costs to a hospital, damage to its reputation and the possibility that staff members may lose their jobs in cases of potential negligence, the health-care system often appears to erect a wall of silence.
In the Halisi case, it took a little over a month for the Winnipeg Regional Healthy Authority to issue a formal written and verbal apology.
Like so many other families, the Halisis have said they are not interested in financial compensation for Ashuza's death. "Nothing can bring her back," Willy Halisi told the Free Press. "No amount of money can do that."
As humans, we are all vulnerable to error, and health-care-related ones occur in even the best of hospitals. There is no intent to harm. The authors note that how an institution deals with an error makes all the difference in how patients and families cope with adverse outcomes.
Health-care providers and laypersons alike are encouraged to read these stories and recognize that the patient's voice is a health-care resource that cannot and should no longer be ignored.
Evelyn Lundeen, a former critical care nurse, is a nursing instructor at Red River College and a Winnipeg-based author and writer.
After the Error
Speaking Out About Patient Safety to Save Lives
By Susan McIver and Robin Wyndham
ECW Press, 254 pages, $20
Republished from the Winnipeg Free Press print edition May 18, 2013 J10