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Patient safety

MUHC withholds info on medical errors

MONTREAL – An access-to-information request made by The Gazette newspaper for a list of medical errors within McGill University Health Centre (MUHC) during the last two years has been rejected.

Under Quebec law, hospitals are required to identify and track these errors, which include preventable infections, drug dosing mistakes and surgical accidents. They are also required to make them public in the interest of patient safety.

Hospital records of risk management committees are confidential, MUHC representative Robert Cox said. “Consequently, I have no other alternative but to deny your request,” Cox wrote.

By contrast, officials at the Centre hospitalier de l’Université de Montréal said they were prepared to release such data, and without the need of an access to-information request.

The MUHC information clampdown has surprised health advocates.

“There’s no legal or legitimate reason not to publish (statistical) data on the matter – unless you have something to hide,” said Paul Brunet, head of the patients’ rights group, the Conseil pour la protection des malades. “I am surprised. I can’t believe it is their corporate position.

“I challenge their management to publish the data, like all good public servants, for the sake of everyone, including their own.”

A coroner’s report into the death of Ivan Todorov, 83, after three months of care at Royal Victoria Hospital, highlighted malnutrition, infection, metabolic complications and gradual multi-organ failure. These were never reported to his family.

Moreover, eight years after the Quebec government adopted Bill 113, requiring hospitals to report to patients “any incident or accident as soon as possible after becoming aware of it,” the provincial Health Department has yet to set up its registry of adverse events.

The provincial registry is expected to start analyzing adverse events data as of next year. In the meantime, each hospital is expected to keep its own records of such incidents and make the data public in their annual reports. This process is independent of complaints lodged by patients with hospital ombudsmen.

No hospital contacted by The Gazette includes adverse events in its annual reports. It’s not clear how Quebec enforces Bill 113. No fines are levied if a hospital fails to record an incident.

According to a study led by University of Toronto health researcher Ross Baker, approximately 24,000 Canadians die each year from preventable medical errors.

The Canadian Adverse Event study was based on data from hospital patients in 2000. Are patients safer now? “We can’t answer that question because we don’t have the data that give us a sense of comparing,” Baker said yesterday. “Most of us feel we haven’t made enough progress to repeat the studies that were so alarming years ago.”

Not much has changed in terms of patient safety in the past 10 years, he said, largely because of inconsistencies in measuring and reporting medical errors, and a climate of fear.

“If you talk to doctors and nurses, they say, ‘I know I should do this, but what will happen if I make these reports?’ ” Baker said.

Posted December 16, 2010