After The Error

McIver Susan B.

Description

Medical errors kill 14,000 people in Canada each year, adversely affect hundreds of thousands and cost close to two billion dollars. But this is not a situation unique to Canada. The NHS frequently comes under fire for misdiagnoses or for completely ignoring patients with fatal symptoms. After The Error is a collection of true stories, and it is the first book anywhere to recognise what patients affected by medical errors, their families and immediate healthcare providers have done to prevent others from enduring similar experiences.

Informations

• Publié par: Ecw Press
• Date de parution: 09 mai 2013
• Nombre de lectures: 0
• EAN13: 9781770903586
• Langue: English

Extrait

For Georgina Hunter
Her personal courage helped usher in a new era in the awareness of medical errors and showed that even one person has the power to create significant change.
“When you speak the unspeakable, something is lost and something is gained. I lost years of my life, but I gained a priceless connection with ethical, caring people.” — Georgina Hunter


ACKNOWLEDGMENTS

We would like to thank the contributors to this book, who were willing to share both their pain and their accomplishments and to persevere through the lengthy writing and editing process. Each one, in a unique way, helped to demonstrate that although medical errors do occur, it is possible to step outside of one’s grief, anger and comfort zone to provide education to the public as well as work for changes in systems, laws and attitudes.
Many friends, relatives and associates have encouraged us in a variety of ways. We would like to mention and thank Georgina Hunter, Harry Goldhar and Dorothy Harp.
Helen Haskell assisted us by contacting potential contributors and providing support during this project.
We would like to especially acknowledge and thank Rhonda Nixon for the role she has played in generously assisting and supporting us over the past three years. Her experience, efforts and friendship were essential to the concept and preparation of this book.
We are indebted to Jack David for seeing the potential in our original concept and accepting this work for publication. The manuscript was greatly improved by the editorial assistance of Crissy Boylan and Kathleen Fraser. Erin Creasey and Athmika Punja deserve mention for their diligence and professionalism in promotion, sales and marketing. Thanks also to Carolyn McNeillie for the cover graphics and Sarah Dunn for publicity.


DISCLAIMER

This book contains stories documenting contributors’ experiences with medical professionals. The authors have taken reasonable steps to verify the contributors’ accounts, and each contributor has declared that the stories are true and accurate. Readers are advised not to rely in any way on the specific facts portrayed in any of the accounts and are prohibited from reproducing, publishing, translating and in any way commercially dealing with, in any medium, the accounts or any portion thereof without the written permission of the authors and the publisher.
A few of the stories in this book were written by the contributors; most were prepared by the authors based on personal interviews, telephone conversations, emails, newspaper and magazine articles, coroners’ reports, medical records, books and articles, notes and rough drafts.


FOREWORD

When a plane crashes, it is national, if not international, news. The question invariably posed is “How did this happen?” The television reporter, standing near the site of the crash, tells us that the black box is being located and that its contents will be meticulously examined for clues about what went wrong.
A 2012 study estimated that 40,000 Canadian patients die every year as a result of medical error. That is the equivalent of 80 jumbo jets crashing every year — one every five days or so. If a plane was crashing every five days, would anybody ever fly? Yet while individual cases of medical error do make headlines, the sheer and unacceptable scale of this worldwide problem is something that most people simply cannot comprehend.
Each story in this book is a black box. Each is a tragedy. But each is also a treasure trove, offering clues about what went wrong. You need only read two or three stories before patterns start to emerge. This book offers lessons, not just about what went wrong in each of these cases, but also about what is going wrong across the world’s health-care systems, and about the factors that transpire to cause tragedy in the very places where we seek relief when we are sick.
A plane’s black box records every bit of data imaginable about the flight in real time. It also records the voices of those at the centre of the unfolding tragedy — the pilots in the cockpit. This book tells the stories of those at the centre of their own unfolding tragedies. In most of the cases, these people died. This book gives them a voice.
When I founded the World Health Organization’s first ever program on patient safety, it was the stories of patients and their relatives that motivated me. I vividly recollect even small details of their descriptions. This book exists because people have volunteered to share their most painful experiences. In doing so, they offer up a challenge to the health-care community, which is to eke out every possible piece of learning from these stories, so that they do not just remain as tragic stories but provide the basis on which improvements are made.
At the centre of this book is the difficult truth that thousands of people die unnecessarily in the hands of our health-care systems. Sometimes these are people who were critically unwell, but often they are people who were not. Yet interwoven through this book are also stories of hope and of individuals who have used their own experiences as a force for good, who have shared their stories so that others may avoid the same fate. The title of this book attests to its ambition — to speak out about patient safety, so that lives may be saved. As you read this book, please think hard. Think what went wrong. Think what needs to change. If we can collectively do this, and act on what we learn, we can make our health-care systems as safe as our airlines are.
Professor Sir Liam Donaldson World Health Organization Envoy for Patient Safety


INTRODUCTION

It takes courage to speak out about medical errors. It takes persistence, stamina and support from others to effect change. This book was written to recognize the patients and families whose activities have helped to lay the foundation of current patient safety programs and who continue to raise awareness, identify problems and provide solutions. Their accomplishments have often come at considerable emotional, psychological and financial expense. Their stories provide examples of what can be done to promote safer health care and also remind readers that in spite of increasing efforts to prevent errors, they continue to devastate lives. The contributors are all Canadians; however, their experiences and achievements speak to the world.
American patients and media have played a significant role in drawing attention to medical errors. In the 1970s and 1980s, medical malpractice claims associated with anesthesia accounted for a disproportionately high payout of medical liability insurance. In the early 1980s, national media publicity turned a harsh spotlight on injuries associated with anesthesia. The Anesthesia Patient Safety Foundation (APSF) was established in 1985 to address these concerns and as a result anesthesiologists have become widely recognized as pioneering leaders in patient safety.
In 1999, the Institute of Medicine (IOM) of the U.S. National Academy of Sciences released its landmark report, To Err Is Human: Building a Safer Health Care System. 1 The report stated that 44,000 to 98,000 preventable deaths occur annually because of medical errors in hospitals alone. At the time, these numbers were startling; however, more recent studies have found medical errors to be much more prevalent.
A survey completed in 2012 revealed that almost one third of Americans reported that either they or a friend or family member had experienced a medical error. 2 Based on a population of approximately 320 million, this survey indicated that close to 100 million Americans have had direct or indirect experience with medical errors. As many as 25 percent of all hospital patients are harmed by medical errors, according to a 2010 report. 3 The study found little evidence that efforts to reduce errors have translated into significant improvements in the overall safety of patients. In 2011, it was reported that adverse events occur in one third of hospital admissions. 4
A Canadian study estimated that 7.5 percent of patients admitted to acute care hospitals in 2000 experienced one or more adverse events 5 and approximately 24,000 patients die annually as a result of adverse events that occur in hospitals. A 2009 report revealed that approximately one in six Canadians said they had experienced at least one error in the previous two years. 6 This translated to 4.2 million adult Canadians. Not all of these reported errors caused even minor harm, but their numbers clearly illustrate the magnitude of the problem.
A 2012 report stated that approximately 38,000 to 43,000 deaths occur annually in Canada in connection with health-care delivery. 7 According to the same report, the actual total number of deaths is undoubtedly much greater because of the high rates of non-reporting. In addition to those who die, there are hundreds of thousands of Canadians who are harmed from health-care delivery.
An Australian study reported in 1995 that there were approximately 230,000 preventable adverse events in hospitals each year, and as a result between 10,000 and 14,000 people died. 8 In 2000, a British study reported that adverse events harmed approximately 10 percent of patients admitted to hospital, or more than 850,000 individuals each year. 9 Many other countries have undertaken similar studies.
The financial costs of medical errors are inextricably intertwined with human suffering. In 2002, following a book reading that I (S.M.) gave in Kelowna, BC, I spoke to a distraught woman whose husband, a tradesman, had undergone what was supposed to be straightforward surgery on his elbow several years before. The surgeon nicked a blood vessel during surgery which eventually resulted in extensive tissue damage. In the intervening years, her husband was unable to work and