What the medical events registry doesn’t report

Nova Scotia’s medical events registry, which is health care’s report card to the public, has such substantial gaps in it that many health failures don’t qualify as reportable events.

Nova Scotia allows for six reporting categories:

  1. surgical events
  2. product or device events
  3. patient protection events
  4. care management events
  5. environmental events
  6. criminal events

Since the registry was launched the number of reportable events in Nova Scotia have risen. But is that due to more errors or a unified system?

In the past our independent health authorities were fairly dismissive about what the medical world classifies as “adverse medical events”. As I have previously written, these have well-defined standards (see: https://helphealthcare.wordpress.com/2013/08/24/the-prevalence-of-medical-mistakes-in-nova-scotia/), which some authorities treated as a joke, claiming a burnt-out light bulb was an example of a reportable event.

In fiscal 2013/14 the new system had a total of 19 reportable events. In 2014-/15 that number rose to 87 events. For the first nine months of fiscal 2015/16 (basically from April to December 2015) there were 99 reportable events. Eight of those 2015 events were categorized as deaths or serious disability resulting from either a diagnosis problem or with care management. That may seem statistically small, but for the patient, their family and friends each event is staggeringly significant.

Each of the six categories have subsections, but there is still a lot they don’t cover. Like the failure to deliver care or capture mistakes. For example, there was a heavy snowstorm on Valentine’s Day 2015. A Cambridge man crawled for an hour on his hands and knees up an icy lane to reach his house. Once inside his family called for an ambulance. The ambulance got stuck attempting to reach him. They called for a second ambulance to help. Once freed from the icy conditions, both ambulances drove away, leaving the patient behind. The next day an ambulance did return to drive him to Halifax for plastic surgery for frostbite.

Ambulances forgetting or abandoning patients is not an event that fits into current reportable categories.

In January, a 40-ish Halifax executive had a ski accident at Wentworth. Briefly unconscious and with temporary paralysis where he could only move his face, he was taken by ambulance to the Colchester East Hants Health Centre in Truro. There he said the doctors focused on his neck. Determining his neck wasn’t broken they released him. But before leaving their care he asked about his spine since he couldn’t move or lift his hands, which pained so much they felt like they have been slammed in a car door. The doctors dismissed his concern and released him.

Within two hours of his release he went into shock. A friend called 8-1-1 for advice then drove the patient, in a car, to the QEII. Within 10 minutes of arriving at the QEII a doctor told him he had a bruised spinal cord. He had surgery to remove a damaged disk, replace it with a cadaver bone and titanium. After five days in hospital he was again released. He had been within millimetres of becoming a quadriplegic. This diagnostic failure doesn’t seem to fit into the perimeters of reportable events. How can that be?

And as study after study has shown, Nova Scotia has among the longest orthopedic wait lists in Canada. In 2014 a 50-ish Metro woman she saw her doctors about hip pain. They put her on a list for an MRI which would lay the groundwork for an appointment with an orthopedic specialist. In late 2015, after 16 months of waiting, she learned it would be another 430 days before she had an MRI because a tech in Yarmouth had quit. This woman bit the bullet and paid $1,840 to have a private New Brunswick clinic conduct an MRI. That MRI showed a rapid decline in her condition which meant she was on a waiting list for the wrong surgeon and needed to see someone with a more narrow, higher specialty.

Her worsening condition moved her to a new waiting list which meant she couldn’t have surgery in Nova Scotia until late 2019 or early 2020. In the meantime, she has to walk with a cane or walker, both of which are a physical and economic hardship since work requires her to stand for hours. The delay also means constant doctors visits, potential hospitalizations and prescriptions to deal with the pain. Given the decline of her hip, there is the fear of total collapse and ensuing hospitalization. Her only other option is to remortgage her house and go to Montreal where she can get surgery. For $20,000. She is trying to get MSI to pay for this care, but that is tied up in paperwork.

The cost and consequences to patients and the province from delayed treatment are not reportable.

The other failure in reporting adverse medical events concerns death. Unless an autopsy is requested most hospital deaths in Nova Scotia are, according to the medical examiner, attributed to the condition the patient presented on admission. So, a patient who is brought to hospital with a heart attack typically has heart attack listed as a cause or contributing factor of death. Any treatment failure, mixed up medication, misdiagnosis or hospital born infection could be excluded from the cause.

This 2013 CBC article says 50 percent of death certificates are inaccurate:

http://www.cbc.ca/news/health/ratemyhospital/story/2013/04/11/cause-death-errors-rmh.html

Equally curious is the lack of reportable complaints about medical devices or products. A woman who went to Valley Regional Hospital in Kentville for hip surgery was dropped three times while being lifted in and out of bed. These repeated drops resulted in a broken hip, arm and collar bone. She went to hospital for one surgery and ended up having four. Painful for her, costly to the system. There have been reports about faulty hospital lifts, but because health care is so secretive that news hasn’t been widely shared. So the patient and public are left wondering if the drops were due to staff incompetence, poor training or faulty equipment?

The Department of Health and Wellness, Nova Scotia Health Authority and IWK have to do better than generic spreadsheets and the request to ‘trust us’. They need to show us where the mistakes are being made so those who may have to place their health and lives in the hands of provincial health professionals know whether or not those people deserve our trust. And the public have a right to know if those with problems have learned from their mistakes and are improving. That is why we need a facility-by-facility breakdown of treatment issues. Only when this is out in the open will we, as well as the practitioners, be able to judge the improvements in care.

Here is an important article to read about Canada’s secret world of medical errors:

http://news.nationalpost.com/health/inside-canadas-secret-world-of-medical-errors-there-is-a-lot-of-lying-theres-a-lot-of-cover-up

 

 

 

 

 

 

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4 Responses to What the medical events registry doesn’t report

  1. kkllkkl says:

    As part of their accreditation by accreditation Canada, Health Centers need to have a reporting system for near miss/good catch and adverse effects.

    A near miss is a patient for which an Xray requisition states that the Right hip needs the Xray and the patient tells the technologist that the problem is on the left, call to physician, correction of the requisition, and Xray of the Left hip, no harm to the patient, but waste of time …

    A true adverse event would be that the patient had the Xray on the Right hip because of the error on the requisition, but this adverse effect now is so complex to report in the computer that it is around 20 minutes that are lost to do so. Nevertheless the employees always find the time to fill a report in the computer when it comes to behavioral issues, i.e. a nurse is asked to do something “urgently” one hour later this is not done yet when she got a remark from the manager or the physician (especially the physician) there is a report in the system. So what was intended to improve care toward the patients is now mostly used to support incompetency and lazziness…

    • woof says:

      Kind of like those complaint forms that don’t exist anymore because there are no more complaints against the system. Now we have comments: positive comments and negative comments, but only comments. Political correctness.

      • Yes. Several years ago the IWK announced on their website that they were no longer accepting complaints. Instead they were considering all comments as “feedback”, as if it was all positive. If you don’t acknowledge negative comments then everything in your world is wonderful.

  2. kkllkkl says:

    break the thermometer and the patient does not have fever…

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