orthopaedic surgery

Ten Years of Surgical Error in Canada

This year the Canadian Medical Protective Association published a decade-long review of surgical safety in Canada. The CMPA is the legal defence insurer of most Canadian physicians. Membership fees are subsidized by the provincial governments, which fund the ‘rigorous defence’ of doctors accused of medical negligence and other offences. Access to the details of CMPA peer reviews is barred to the public.

Albeit generally uninformative, “Surgical Safety in Canada” does provide a glimpse into the relative frequency Canadian patients suffer ‘never events’. A ‘never event’ is a medical error that medical professionals agree should not happen under any circumstance, such as operating on the wrong limb or electively performing open wound surgery in an unsterile cast room.

Of the 1583 surgical incidents assessed, 190 were classified as ‘never events’ by the CMPA.

When individual cases were assessed by experts of similar training and experience, over half were flagged with criticisms of care — 839 of 1583 surgical incidents.

The sample excluded obstetrics-related cases due to the associated “high costs” (no further explanation given) and incidents that resulted in class action lawsuits to avoid “overweighting” of an issue.

The CMPA review cites the landmark 2004 Baker (et al.) study of Canadian acute care hospitals, which reported 7.5 per 100 hospital admissions result in an adverse event, 40% of which are considered preventable and 20% of which result in death. It also makes references to the Zeegers (et al.) and Rogers (et al.) studies, which indicate over half of hospital patient safety incidents can be attributed to surgical treatment and care.

Yet, Canadian patients are left in the dark as to the quality of their local hospital. The most precisely the CMPA categorizes heath regions in reports available to the public are by “Ontario”, “Quebec”, and “Rest of Canada”. A possible patient safety improvement lies south of the border.

For over ten years, Minnesota hospitals are required to disclose adverse events to the state health department under the Adverse Health Events Reporting Law. The law then requires the health department to publish annual reports by facility with analyses, corrections implemented by facilities, and recommendations for improvement. Finally, the results are available by year and hospital on the website of the state health department.

Many American states use adverse event reporting systems; however, Minnesota, Colorado, and New Hampshire produce annual public reports with both aggregate data and facility-specific information. BC health authorities and the Fraser Institute have produced hospital report cards sporadically, but never so regularly to a depth required by law.

A decade since the implementation of the Adverse Health Events Reporting Law, Minnesota has experienced a decrease in deaths and serious disabilities from adverse events, in addition to a significant increase in safety satisfaction of both health practitioners and patients.

References:

Baker GR, Norton PG, Flintoft V, et al. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004; 170(11): 1678-1686.
Canadian Medical Protective Association. Surgical safety in Canada: a 10-year review of CMPA and HIROC medico-legal data. CMPA: Ottawa, 2016.

Rogers SO, Gawande AA, Kwaan M, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery. 2006, 140(1): 25-33.

Zegers M, de Bruijne MC, de Keizer B, et al. The incidence, root-causes, and outcomes of adverse events in surgical units: Implication for potential prevention strategies. Patient Safety in Surgery [Internet]. 2011, 5:13.