Medical Error Rates in Quebec

Some things never seem to change. One of them is the issue of medical error rates. Although I have not had access to the detailed data in order to draw informed conclusions, what I can safely say is that medical errors and mistakes have been a mainstay of Lean Six Sigma case examples of areas for improvement and the poster child for the idea that 99% success rate is not good enough (3.8 long term sigma Z).

This Quebec became the first province to release provincial medical error data. The Toronto Star reports:

Medication errors and patient falls account for more than two-thirds of medical mishaps in the Quebec health-care system, according to newly released provincial data.

In making the figures public, Quebec has become the first province to publish a standardized list of medical errors reported by hospitals, community health clinics and nursing homes.

In the six-month period between April and September 2011, about 270 provincial health-care facilities reported 179,000 incidents, including patient falls, medication errors and botched tests. There were 75 deaths during this time linked to various medical mishaps.

Patient falls accounted for 35 per cent of all incidents, while medication errors were responsible for about 30 per cent of the blunders. The remaining mishaps were related to treatment, tests, medical and non-medical equipment.

Twenty-four people died due to complications from falling, while medication errors, such as staff administering incorrect dosages or giving prescriptions to the wrong patients, contributed to the deaths of four people.

Fifty-one per cent of reported incidents affected patients over the age of 74.

While Quebec health minister Yves Bolduc hailed his government as a “pioneer” for releasing the figures, critics pointed out that the information provides only part of the picture given that about one-third of the province’s health-care facilities failed to provide complete data. In fact, nine hospitals didn’t report any incidents, citing “technical” problems.

“It’s ridiculous,” said Jean-Pierre Ménard, a Montreal medical malpractice lawyer. “Patient safety and care is such a huge issue and yet the government allows these hospitals to simply not report data.”

Ménard launched a campaign 10 years ago to persuade the province to collect information on medical incidents after a 28-year-old woman died in hospital from an adverse reaction to medication. He lamented the fact that it took the province nine years to enforce the provisions in Bill 113, adopted in 2002, that require health-care facilities to disclose accidents and tell patients and their families when errors are made.

He also said hospitals have no excuse for making so many medication-related errors, and slammed the province for failing to release a plan explaining how it would address the mistakes identified in the data.

“There are very simple ways to ensure medication errors don’t occur, whether it’s better training of nurses, or working with pharmaceutical companies to help change warnings on bottles,” he said. “We have no plan and that’s unacceptable.”

Quebec sees about 3.2 million visits to emergency rooms, nearly 6 million medical appointments, 500,000 surgeries, and 19 million days spent by patients in hospitals each year, according to health ministry statistics.

The province says it will publish updated statistics in June 2012.

Angela Baker, a spokesperson for the Canadian Institute for Health Information (CIHI), a non-profit corporation that conducts research on the country’s health system, says her organization isn’t aware of another report of this magnitude, but noted CIHI does collect data on medication incidents from hospitals and long-term care facilities through its National System of Incident Reporting.

In Ontario, hospitals are required to disclose to patients or families all critical events that resulted in serious injury or death to the patient. As of October, all hospitals in the province are required to report critical incidents related to medication to CIHI, but there is still no provincial requirement to publicly report all incidents.