Many a slip...

http://www.princegeorgecitizen.com/section/princegeorge0113

November 4, 2013

Arthur WILLIAMS
Citizen staff

Doctors, nurses, pharmacists and other healthcare professionals are human beings.

They make mistakes, and some of those mistakes kill. According to a 2004 study published in the Canadian Medical Association Journal 9,000 to 24,000 Canadians per year die as a result of preventable medical errors.

Dr. Brian Goldman - veteran ER doctor at Mount Sinai Hospital in Toronto, host of CBC Radio's White Coat, Black Art and author of The Night Shift: Real Life in the Heart of the ER -believes its time for doctors and medical professions to start talking about their mistakes, and what can be done to prevent them in the future.

"The [healthcare] system should begin by admitting that humans make mistakes," Goldman said. "To my colleagues my call is to be curious, not ashamed, of your mistakes. You can't take them back, you can only pay them forward."

Goldman was in Prince George on Saturday to present Mea Culpa, a lecture based on his 2011 TEDX talk Doctors Make Mistakes. Can We Talk About That? which has been viewed more than 842,000 times online.

The workplace culture of hospitals is that mistakes should never happen, Goldman said. One mistake might be viewed as momentary lapse, but multiple mistakes is seen as a sign of incompetence, he said.

As a result medical professionals rarely want to discuss or even think about their mistakes, he said.

"... [I] realized after many, many years the virtue of admitting mistakes," Goldman said. "If you learn nothing [else] from me today, it's that every single success I've had comes from failure. I wise urologist once told me that good judgment comes from experience, and experience comes from bad judgment."

Medical errors come in many forms including: preventable hospital infections; misdiagnosis of x-rays, biopsy results, CT scans or other tests; errors in prescribing or administering medication; and misdiagnosis or surgical errors caused by staff being overtired, too busy or coming to incorrect conclusions based on various factors.

Goldman played an excerpt from a radio interview with Dr. Michael Gardam, a Toronto-based epidemiologist who has researched the causes of hospital-based infections.

"Most of us [medical professionals] have been taught infections in hospitals are a cost of doing business. They just happen," Gardam said.

In fact, he said, up to one third of the 200,000-plus hospital-acquired infections each year in Canada could be prevented. Between 8,000 and 12,000 people in Canada die each year as a result or complication of getting an infection while in hospital.

Many of those infections could be prevented by very simple measures, like ensuing staff wash their hands each time they interact with a patient, he said.

"As this is a bit of a confessional... as a medical resident it was very rare I washed my hands," Gardam said.

Goldman said it's easy to fall out of the habit of doing basic things like hand washing and pre-surgery checklists - either as a result of rules overload, bad role models or just "getting away with it."

"If you break the rule and nothing happens, after two or three times that's the new rule," he said. "If you have a leader in the hospital who doesn't wash their hands, soon enough you'll get followers who don't wash their hands."

In the case of incorrect doses of medications, one study of 19 hospitals found 19 per cent of doses administered where in error, of which seven per cent were potentially-harmful, he said.

The three most common type of errors were errors mixing the medication, providing the wrong medication to the wrong patient or prescribing or administrating the wrong dosage amount, he said.

In one incident in Alberta, a chemotherapy patient was given four days worth of medication in four hours, he said. All they could do for the patient was make her comfortable as she died.

In an excerpt from a radio interview with Laura Adams, president of the Rhode Island Quality Institute which is working to improve healthcare in Rhode Island, Adams talked about a mistake she made as a 22-year-old registered nurse working at a hospital.

Adams said she was about to leave the hospital at the end of her shift when she got an urgent page from a surgeon.

"He said, 'I don't know what pre-surgery medication you gave this seven-year-old child, but we're losing her. You've got to tell us what you gave her,'" she said.

Adams said she rushed back to her work station, and immediately realized she'd given the girl a massive overdose of medication. She said she stayed at the hospital and prayed for a miracle to save the girl from her mistake.

"She survived my care that night, but just barely," Adams said.

Goldman said the vast majority of medical professionals care deeply about helping their patients, and carry a deep sense of guilt about patients who suffered or died as a result of their mistakes.

"Most of us will carry the names of those patients to our graves," he said.

In an excerpt from a radio interview with a doctor from Victoria, the doctor said he'd misdiagnosed an autistic man. The man had been yelling and thrashing, and care home staff told the doctor, "He always gets this way when he's constipated."

The doctor treated the man for constipation and sent him home. The next day he heard the man had died -an autopsy showed that he'd had a ruptured appendix.

It's easy to make snap diagnosis based on a patients past history or immediate symptoms, instead of taking the time to consider all the possibilities, Goldman said. Especially when there is 10 or 15 patients backed up in the emergency room and more coming in constantly.

Goldman urged patients and their families to ask questions like "What else could it be?" or "What is the worst thing which could be causing these symptoms?"

Doctors, and especially those doing residencies, may often spend long hours at the hospitals or on call, Goldman said. Excessive sleep deprivation can impair a doctor's judgment as much as being drunk.

"Up until the 1980s, sleep deprivation was a right of passage," Goldman said.

Following the death a teenager in New York which was discovered to be partly caused by the sleep deprivation of the attending physician, doctors and nurses are supposed to go home rather than work 24, 36 or more hours straight.

In practice, many don't because the culture of hospitals encourages doctors to stay, he said. In smaller centres there may only be one specialist available on call.

"In a smaller place you may have a choice between an OB/GYN [obstetrician and gynecologist] who has been up 24 hours or 36 hours or nobody at all."

And sometimes if the physician who started treating a patient does go home, it can result in mistakes occurring because important information isn't passed on to the next doctor, he said.

As demand on the healthcare system grows, medical professionals are being pressured to do more with less, he said. There are hospitals and health authorities which are pioneering methods to reduce mistakes, infections and other medical errors, but they do take manpower and resources.

"We have to decide if we, as a society, are willing to pay for safety," Goldman said. "That's an open question, I don't know if our governments want to do that."

To watch Goldman's TEDX talk - titled Doctors Make Mistakes. Can We Talk About It? - go online to www.ted.com and search for Brian Goldman. Or scan this page with Layar.

Goldman said it's easy to

Goldman said it's easy to fall out of the habit of doing basic things like hand washing and pre-surgery checklists - either as a result of rules overload, bad role models or just "getting away with it."

"If you break the rule and nothing happens, after two or three times that's the new rule,"

From working in healthcare, I know there is "rules overload". After completing my nursing diploma, I wanted to ensure I was the best I could be, and I thought the way to do that was to work towards my degree - so I immediately started on my post-RN nursing degree.

I started in nursing in 1994. Many times I could see the rules I had learned and the rules I was continuing to learn were very nice in theory, but couldn't be applied. When I tried to apply them, leaders, formal and informal, were unhelpful, to say the least.

It had been very confusing for me, but I'm beginning to see things much more clearly.

As demand on the healthcare system grows, medical professionals are being pressured to do more with less, he said. There are hospitals and health authorities which are pioneering methods to reduce mistakes, infections and other medical errors, but they do take manpower and resources.

"We have to decide if we, as a society, are willing to pay for safety," Goldman said. "That's an open question, I don't know if our governments want to do that."

The CMPA and CPSO are supported by our government.

So is CPSI.

http://www.patientsafetyinstitute.ca/English/About/Documents/CPSI%20Annual%20Review%202013.pdf

I could be very wrong, but to me, it looks like CPSI is where we learn what needs to be done.

CPSO is "real life".

http://www.cpso.on.ca/aboutus/

CMPA are the "leaders" with power and control.

If the CMPA dismisses legitimate complaints, as their hired gun medical experts and their excellent lawyers will, and if need be, they break a few rules to "win" and "nothing happens", (and money appears to be saved), then power increases, and safety decreases.

The government seems to fully support the power of the CMPA.

Unless and until the government makes patient safety a priorty, we can never have a just culture of safety.

ASK.LISTEN.TALK

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