Editorials

Winnipeg Free Press - PRINT EDITION

To reduce medical tragedies

By: Editorial

Posted: 02/28/2012 1:00 AM | Comments: 0

(DALE CUMMINGS/ WINNIPEG FREE PRESS)

For all the work that has gone into reducing medical errors, Manitobans would have a hard time finding out how big the problem is or how much progress has been made. Patients and their families continue to be shocked by the tragedies that can happen when mistakes are made in health-care facilities. And it is difficult to know if the medical system has benefited from the lessons learned at patients' expense.

The death of Heather Brenan, who collapsed at her Winnipeg doorstep in January after being discharged from the Seven Oaks Hospital emergency room, shows signs of a colossal breakdown in care. The Winnipeg Regional Health Authority is investigating the critical incident. Ms. Brenan's daughter said an autopsy shows that she died after a blood clot in a leg caused a pulmonary embolism. Her family is asking why her mother didn't get her prescribed blood thinners while in ER care, why she was discharged despite the fact she was weak, couldn't eat and was having difficulty breathing, and why she was sent home alone in a taxi late at night despite the fact she didn't have her house keys. At discharge, the hospital called a friend. Another friend was waiting for Ms. Brenan at the house but couldn't get the woman into her home. She died the next day in hospital.

There is a report her physician looked at her charts and cleared her for discharge. Family and friends say that Ms. Brenan, a retired Free Press employee, was told by staff that she was taking up a bed that a sick person could be occupying. The fact that she was on a gurney indicates that the ward was crowded, under pressure to move people out.

Deaths due to medical mishap, preventable or otherwise, are not uncommon, although they are a small percentage of critical incidents and smaller percentage of admissions. But harm due to mistakes is a significant problem -- up to 10 per cent of admissions, some studies have said. The WRHA compiles statistics and has studied the problem of deaths and injuries due to mishap. But that data is not readily available. The authority does not post them on its website, and the Health Department has only a roundup report for 2007-2010 available.

Reporting of critical incidents by hospital personnel became mandatory in 2006. In 2009, 506 reports were made to the WRHA, indicating there is a way to go to get all staff conforming to the law. Good progress toward reducing errors and fixing systemic weaknesses requires the system to have a good picture of what's going on. Patients and families must be routinely encouraged at bedside to report errors so that more learning can be done faster to prevent such tragedies.

Republished from the Winnipeg Free Press print edition February 28, 2012 A10

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