A teenage boy dies of a heart virus after being misdiagnosed with liver disease. Another young man's severe head injury goes virtually untreated by nurses and doctors for days before he finally succumbs to the wounds. A war veteran is ignored in an emergency department examining room as he suffers a debilitating cardiac arrest.
All three died in the wake of apparent medical error and, until recently, their stories would likely have ended there or in some closed hospital boardroom, the incidents kept quiet by health professionals reluctant to openly admit mistakes. But these patients' loved ones are part of an unusual new group determined to see the health-care system exposed for these kinds of missteps that leave many people worse off, not better, after seeking medical help.
Confronting the epidemic of "adverse events" has become a hot topic in the health-care system lately. A study released just last week exposed the poor hand-washing habits of doctors at a Montreal hospital, another report showed that death rates at many of the country's worst-performing hospitals have not improved in the last year, and figures released by Winnipeg health officials suggested that 32 hospital patients died in 2008 for reasons other than their underlying medical condition. Yet the issue is often couched in clinically abstract terms. Patients for Patient Safety Canada, on the other hand, is trying to humanize that analytical discourse, publicizing some of the thousands of heart-breaking tales behind the statistics of medical error.
Group members have addressed physicians and nurses at conferences, worked with the very hospitals that failed their family members and even written articles for medical journals.
"We were a pretty healthy family. We hadn't asked much of the system, and when we did, it failed us," says Theresa Malloy-Miller, mother of the teen killed by a heart virus. "We were just in zombie land. One day you have a healthy son, and one day you don't have a son at all.... It just didn't make sense to us."
Many members of the patients' organization -- part of an international network of such groups -- faced brick walls at first as they tried to get to the bottom of what went wrong, but have managed to wring apologies, disciplinary action and changes aimed at avoiding more tragedy. "I don't want to go around as a vindictive person," said Donna Davis, a nurse and mother of the brain-injured Saskatchewan teenager. "You've got to channel it into something constructive."
A few months ago, she spoke at the country's major patient-safety congress. The group has advice for patients and their families, as well, urging them to monitor the care they receive, and alert doctors and nurses if it seems something is going wrong.
It goes wrong fairly often. An eye-opening study published in 2004 estimated that 9,000 to 23,000 Canadian patients die yearly as a result of preventable adverse events, out of 2½ million annual hospital admissions.
Last week, the Winnipeg Regional Health Authority became the first hospital organization in Canada to release figures on the number of its patients who died due to medical care, not their underlying illness, and admitted that at least some of the deaths were likely preventable. The revelation followed the demise of a man who had waited 34 hours for help in the Winnipeg Health Sciences' Centre emergency department.
Led by the five-year-old Canadian Patient Safety Institute, projects have been launched across the country in recent years to try to make going to the hospital less risky, though there is little data yet on what progress has been made. The patients' stories make clear why it is considered such a pressing issue.
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