Nova Scotia’s shortage of doctors and nurses has focused attention and conversation on how tired these professionals are. They’re exhausted from the extra demands imposed by the pandemic.
There is sort of a pandemic-induced disconnect because with the near shutdown of hospitals – the pandemic made them less accessible to the public, fewer people wandering about and medicine-by-appointment – has made them look calmer. I’ve been in Valley Regional seven times in eight months. The halls, entrance atrium and other waiting areas are empty or sparsely populated. They seem quiet and unhurried compared to how they were in the nine months in 2009-10 when I made prolonged daily visits to VRH.
While the hospital seems calm, orderly and controlled a line in a recent obituary suggests all is not well. It read, “Ron left at 4:00 a.m. May 11th due to asphyxiation of barium as a complication of a barium x-ray. Sadly, there is no way to cleanse such material from the lungs.”
No, there is no way to cleanse barium from lungs, but there are procedures to ensure it and other liquids don’t get to the lungs. For this to happen is the most egregious failure of medical standards. Someone was sloppy either trying to cut corners or too impatient to wait for a colleague.
The procedure for inserting a tube into a patient requires an x-ray to ensure the tube has gone to the correct area so that a liquid, food or medication doesn’t go to a lung. Otherwise, the patient dies of asphyxiation, as this man did.
The family have cause for a lawsuit. How did this happen? No one will probably know because of the potential liability.
There is a category in medicine know as Adverse Medical Events. I’ve written about them before:
As I wrote in 2013 the 2004 Canadian Adverse Medical Events study said as many as 24,000 Canadians die in hospital each year because of a mistake. That’s more than the 7,348 Canadians who died in combat in each year of World War Two.
In the United States, ABC World News reported medical researchers found that one-in-three hospital admissions resulted in a mistake.
Dr. Patrick Croskerry, a senior medical researcher at Dalhousie University’s Faculty of Medicine, and an expert on patient safety, agrees that one-in-three hospital admissions can result in harm to the patient. The number of deaths in Canadian hospitals is equal to the crash of two Boeing 737s a week.
There are so many errors and mistakes in health care that medicine has a three-tier rating system for them. The lowest level, according to Dr. CrosKerry is the “medical error”. This can be as simple as the wrong chart being placed with a patient. “Those people who think about these things say that 80-90 percent of all errors that occur in hospital have no consequences. They get detected, corrected and don’t go anywhere. A medical error doesn’t mean anything happened to the patient.”
Next is the “adverse medical event” which means an error has consequences for the patient. “The adverse event is defined according to its degree of severity,” says Dr. Croskerry. “At the least severe end, an adverse event prolongs a hospital stay. The next level is temporary injury where you actually had something physically go wrong, but it was only temporary. Next is permanent injury where it left permanent damage. The next level up is death.”
The final category, the “never event”, is the classification for a mistake so outrageous it should never happen. Like operating on the wrong patient or wrong limb or leaving foreign objects inside a patient. Pumping barium into a patient’s lung is a prime example of a “never event”.
Nova Scotia has a Serious Reportable Events website. https://novascotia.ca/dhw/hsq/serious-reportable-events.asp
It’s watered down to give us confidence in the system. It doesn’t mention Adverse Medical Events, instead we have a menu of selections no doubt designed to give comfort to worried, fearful and/or grieving families. The NSHA and IWK track: surgical events, product or device events, patient protection events, care management events, environmental events and criminal events. The bulk of these options suggest outside forces which the NSHA defends patients against. But what about the barium in a lung?
Was that an individual’s failure or was it driven by corporate sloppiness or a drive to cut corners and save $$ or from pushing people too far and hard? Whatever, the patient died from an entirely preventable procedure. That is outrageous.
Looking at the Serious Reportable Events website is only moderately comforting. There are six options under the first heading: Surgical Events.
A – Surgery performed on a wrong body part
B – Surgery performed on the wrong patient
C – The wrong surgical procedure performed on a patient
D – Retention of a foreign object in a patient after surgery or other procedure
E – Death during or immediately after surgery of an ASA classification I-II patient
F – An adverse health event leading to death or serious disability associated with any other surgical event while a patient is receiving a health care service provided by a NSHA or the IWK Health Centre.
We don’t have numbers for 2023-24, but in 2022-23 there were 10 events. Nine of those events were foreign objects left inside a patient! This should be something we have better control over.
In 2021-22 there were six such surgical events. Twice the wrong body part was operated on and four patients had items left inside them.
In 2020-21 there were six surgical events. One patient had the wrong body part operated on, one patient had the wrong procedure done, and four patients had items left inside them.
In 2019-20 there were five surgical events. One patient had the wrong body part operated on, and four patients had items left inside them.
In 2018-19 there were eight surgical events. One patient had the wrong body part operated on, one surgery was done on the wrong patient, one patient had the wrong procedure done, four patients had items left inside them, and one patient died or had a serious disability due to their surgery.
In 2017-18 there were 11 surgical events. Two patients had the wrong body part operated on, eight patients had items left inside them, and one patient died or had a serious disability due to their surgery.
In 2016-17 there were 14 surgical events. One patient had the wrong body part operated on, 10 patients had items left inside them, and three patients died or had a serious disability due to their surgery.
In 2015-16 there were 15 surgical events. Two patients had the wrong body part operated on, one patient had the wrong procedure done, eight patients had items left inside them, and four patients died or had a serious disability due to their surgery.
In 2014-15 there were 13 surgical events. Two patients had the wrong body part operated on, seven patients had items left inside them, two patients died during or immediately after surgery, and two patients died or had a serious disability due to their surgery.
In 2013-14 there were only two surgical events reported in the fourth quarter of the year. Two patients died or had a serious disability due to their surgery.
Looking at all six major categories we get 19 events in the last quarter of 2013-14, 87 in 2014-15, 128 in 2015-16, 142 for 2016-17, 112 for 2017-18, 133 in 2018-19, 85 in 2019-20, 83 for 2020-21, and 78 in 2021-22.
You might think that the declining number of reportable events in 2019-2022 is a positive for health care. But this is the pandemic period and far fewer surgeries were conducted during COVID. People have had to resort to freedom of information requests to get numbers, but as samples of the lower volume of surgeries, in July 2020 it was reported that 3,600 procedures had been cancelled. In January 2022 2,512 surgeries were cancelled. It sounds like we reduced surgeries during the pandemic by 24,000+ per year. So we shouldn’t take comfort in the lower harm numbers. If anything, adverse medical events may be on the rise. Remember Ron suffocating from barium delivered to his lungs in one of the province’s major hospitals?
Tired and overworked medical professionals should be a bigger concern to the NSHA and government than the platitudes we have heard.
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I have a postgraduate qualification in diagnostic radiology and have done hundreds, if not thousands of barium studies. I presume a nasogastric tube was put in the wrong place, but I question why this tube was there in the first place. I’ve never used one for upper GIs. Perhaps the patient was unconscious. You’d have to think very carefully as there’s a monstrous # of things that can go wrong. There’s also a contrast medium called Gastrographin which is iodine based and less likely to cause trouble if it ends up in the lung , and there’s ultrasounds and CT scans. We don’t know enough of the details here
We don’t know more than what the family posted in the obituary, which was an extraordinary thing to write. I suppose they included that detail to explain to family and friends what happened, since this sounds like his illness was unexpected. Certainly his death was.
The fact this was done at 4 am raises a lot of questions. In my experience there typically aren’t specialists on-site at that hour. They may be called in in extraordinary circumstances. So was someone groggy from sleep? Or did someone on staff over-step their ability? Was this done without appropriate supervision? We had a family member who had to have a tube inserted and that was done under strict procedures which included an x-ray machine brought to the patient bed to ensure the tube was in the proper place before the next steps took place.
This has always stayed with me because while at that same hospital I was told of a patient whose feeding tube went to the wrong destination. That patient also died, looking into the face of the person killing them.
The fear of litigation and of harming a reputation and career means we will never know the full details. Officially, medical secrecy is respecting patient privacy. In reality it’s covering someone’s ass. Looking at those other ‘reportable events’, I think the consistent level of surgical items left inside a patient is truly troubling. That level of consistency makes me wonder if it is the same medical team in the same hospital who do this? Again, we won’t know because the NSHA doesn’t want to undermine confidence in a facility or medical professionals. Which means if we have a hotbed of failure they’re okay with that in the mythical belief they will somehow correct it. Not telling the public of hotbeds of failure is a denial of informed consent.