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This article was published 1/11/2010 (3299 days ago), so information in it may no longer be current.
Health officials will review how to improve patient transfers and reduce hospital infections after a year-long study of deaths in city hospitals found medical care could have been better in nearly half of all cases.
The findings of the Winnipeg Regional Health Authority's mortality review, obtained through a freedom of information request, show 44 per cent of patient deaths were associated with 17 recurring themes — including severe blood poisoning and procedural complications — though health officials say they still don't know whether or not they contributed to the patient deaths.
Between Feb. 1, 2008 and Jan. 31, 2009, nurse auditors screened the charts of all 2,893 adult patients who died in city hospitals and looked for clues — such as harm incurred while in hospital or an adverse drug reaction — that they say should be reviewed to see if medical care could have been improved.
Review teams found that 894 cases required further review, including 287 cases that involved hospital-acquired infections such as pneumonia, 190 related to the need for earlier recognition of the patient's problem, 188 associated with facility transfers, and 126 which involved falls, bedsores, or procedural complications.
The 894 cases included 19 critical incidents that were already under review.
Seven working groups have been struck to examine the themes in more detail to determine if a broader policy or system change could improve medical care.
"You could only learn so much by examining one case in detail," said Kaaren Neufeld, WRHA's chief quality officer.
"There is potential for learning when you have a cluster of cases that come together and you look at them as a whole."
Hospital deaths are usually only investigated if they are labelled a critical incident. WRHA officials initiated the broad hospital-death review to improve their patient safety record, on the heels of 2004-2005 national data that showed the number of deaths in city hospitals was slightly above average.
The report cited an example of a patient who was transferred to different hospitals six times in a 24-day period, in addition to two transfers within a hospital. On the final transfer, the patient was sent from an out-of-province hospital to a Winnipeg intensive care unit, where the patient died.
Another patient who may have benefitted from earlier treatment, the report said, was someone who was triaged as less urgent in a city emergency room. The patient arrived with shortness of breath and abdominal bloating, and was accompanied by a support worker who described their condition as "different from normal."
The patient waited for 40 minutes to be assessed by a nurse and 75 minutes to see a physician, but deteriorated rapidly and became unresponsive. The report said the patient was transferred to the ICU where they died the same night.
Neufeld said the recurring themes didn't necessarily cause the patient deaths, and the working groups will be able to issue recommendations on how such complications could be prevented.
"You can't make a leap from the theme to the number on the side and say it caused this many deaths," Neufeld said.
The final report said "utilization of project findings has been minimal to date" and participants were mixed on the value of the review, saying "some perceived that the project identified gaps and learning opportunities while others felt that it confirmed what was already known."
Dr. Brock Wright, the WRHA's chief medical officer and senior vice-president of clinical services, said that some working groups have issued preliminary findings, though it's too early to tell whether the in-depth review proved useful.
How did WRHA review patient deaths in city hospitals?
Between Feb. 1 2008 and Jan. 31, 2009, nurse auditors screened the charts of all 2,893 adult deaths in city hospitals and looked for clues — such as harm or trauma incurred while in hospital or an adverse drug reaction — that it should be reviewed further to see if medical care could be improved.
What did the review find?
Forty-four per cent of all deaths, or 894 cases, required further review, including 287 cases that involved hospital-acquired infections such as pneumonia, 190 related to the need for earlier recognition of the patient's problem, 188 associated with facility transfers, and 126 that involved falls, bedsores, or procedural complications. A total of 17 recurring themes were noted, including inadequate pain control, recent surgery, medication error and inability to reach a doctor.
What happens next?
WRHA has struck seven working groups to examine key themes, including hospital transfers and hospital-acquired infections and severe sepsis. They will recommend whether changes be made to improve how the system works.