The errors of our ways

Hospitals are dangerous places. Sick patients on multiple medications, undergoing numerous procedures and cared for in rotating shifts by an increasing number and disciplinary complexity of health care professionals make it a sure bet that mistakes will occur. Thus, the Canadian study of medical error recently launched by co-investigators Ross Baker and Peter Norton¹ (see News, p. 181) is bound to confirm what similar studies in the US, Australia, Sweden and the UK have shown: medical error is alarmingly frequent. If we extrapolate from the US Institute of Medicine's recent and much-cited study,² we should not be surprised to learn that there are between 4000 and 9000 preventable deaths among hospitalized patients every year.

Canada, like most Western countries, has no systematic national approach to monitoring and preventing medical error. In the aviation industry, reporting of error is not only encouraged but required; in health care, the problem too readily defaults to malpractice lawyers. Our system of malpractice insurance and compensation for injuries requires that blame be placed on the individual practitioner. Lawyers on both sides present differing constructions of what occurred with the prime objective of increasing or decreasing any sums awarded. From the cacophony of allegations and denials, our understanding of medical error arises as an elusive byproduct. In this system, the truth is relative and prevention is irrelative.

The detection of adverse events through malpractice claims is also inherently spotty: the majority of cases that land in the courts involve no adverse event, and few involve real negligence; in fact, the genuine cases of adverse events and negligence tend not to be brought forward.³ As a method of compensating the injured, this system is not only ineffective but unfair, for it favours those who have the stamina and the means to seek help from the courts: generally, this means the young and the wealthy, not the old and the poor.⁴

If we relied on pilot malpractice insurance to improve airline safety, no one would fly on commercial airlines. In contrast to our reliance on professional malpractice insurance in health care, the airline industry aggressively collects and reports errors and near misses, evaluates the reports, and then institutes preventive measures. The focus is not on blaming individuals but on preventing them through improvements to the environments in which those individuals work.

We need to do the same in health care. We need a system that will encourage, not discourage, the reporting of error, that will focus on quality improvement and prevention rather than on individual blame, and that will compensate all patients who are harmed — quickly, equitably and consistently.⁵ It is important, before Baker and Norton's study findings are released in 2003, that health care professions advocate the development of a national system of medical error reporting and no-fault medical error insurance. The Royal College of Physicians and Surgeons of Canada has taken a lead. The national medical, nursing and hospital associations must also get involved. The time is now — not 2 years from now, when the headlines proclaim that hospitals are dangerous places. — CMAJ