More than a decade late and half the size of the U.S. ver­sion, Canada’s hos­pi­tal “nev­er” list falls short in giv­ing patients and fam­i­lies the pro­tec­tion they need

(Pub­lished in The Huff­in­g­ton Post, Sep­tem­ber 23, 2015)

As of last Fri­day, saw­ing off the wrong limb became a “nev­er” event in Cana­da. It’s one of 15 inci­dents the Cana­di­an Patient Safe­ty Insti­tute and Health Qual­i­ty Ontario say are pre­ventable “using orga­ni­za­tion­al checks and bal­ances.” It is the first nev­er list in Cana­da for which there is nation­al con­sen­sus, accord­ing to the report

But will it real­ly do as much as it could to make patients safer? And since Canada’s list is a decade late and half the size com­pared with the U.S. ver­sion, you might won­der what else has been missed. The answer is plen­ty.

The idea of nev­er events was first put for­ward by the U.S. Nation­al Qual­i­ty Forum (NQF) in 2002. Since that time, they have moved on to expand the list to 29 inci­dents ⎯ twice the num­ber the Cana­di­an report has come up with ⎯ and have changed the term to Seri­ous Reportable Events. More on that lat­er.

What is on ⎯ and off ⎯ Canada’s new list is reveal­ing. For instance, in the U.S. mod­el, med­ica­tion errors (which are a lead­ing cause of hos­pi­tal harm and add avoid­able costs to the health­care sys­tem) are list­ed as seri­ous reportable events. That includes such things as giv­ing med­ica­tion to the wrong patient, giv­ing the wrong med­ica­tion, giv­ing the wrong dose or deliv­er­ing it by the wrong route. These events are not includ­ed in Canada’s ver­sion.

Since 2002, patient death or seri­ous injury asso­ci­at­ed with a fall in a hos­pi­tal has been a nev­er event in the U.S. Hos­pi­tal falls are not includ­ed on the Cana­di­an list because the authors say they are “not always avoid­able.” In the U.S., they are so impor­tant to avoid and so strong­ly viewed as being pre­ventable that the U.S. Medicare and Med­ic­aid sys­tems will not reim­burse hos­pi­tals in sit­u­a­tions where falls result in death or seri­ous injury to a patient.

Death or seri­ous injury con­nect­ed with the use of hos­pi­tal restraints and bed rails was also inten­tion­al­ly exclud­ed from Canada’s list. It’s a long-standing nev­er event in the U.S.

And here’s one that’s real­ly hard to fath­om. U.S. author­i­ties say mater­nal death asso­ci­at­ed with labor or deliv­ery in a low-risk preg­nan­cy must nev­er hap­pen. Cana­da claims these deaths are “not always entire­ly pre­ventable,” so they’re not con­sid­ered a nev­er event.

Then there is the rather alarm­ing stan­dard Cana­da is set­ting when it comes to sex­u­al or phys­i­cal assault in a hos­pi­tal. Canada’s view is that these inci­dents are “hard to reli­ably pre­vent” and that they are crim­i­nal mat­ters in any event. The authors of the Cana­di­an report say they don’t belong on their nev­er list. U.S. health­care experts say this kind of abuse is a nev­er event for which hos­pi­tals must take respon­si­bil­i­ty.

The U.S. has had more than a decade to refine and test its nev­er list. It has been sub­ject­ed to intense scruti­ny from every imag­in­able source, includ­ing a very active patient safe­ty move­ment. Can we real­ly believe the “light” edi­tion of Canada’s untest­ed nev­er list is going to keep patients safer than the U.S. ver­sion?

In addi­tion to hav­ing a more inclu­sive list, the U.S. has shift­ed its focus from nev­er events to what it calls Seri­ous Reportable Events.

The empha­sis here is on “reportable.” NQF strong­ly urges manda­to­ry report­ing of such inci­dents as a key patient safe­ty mea­sure. A num­ber of states have passed laws requir­ing hos­pi­tals to report these events. The authors of the Cana­di­an list only want to encour­age such report­ing, even though dis­clo­sure, trans­paren­cy and report­ing have become uni­ver­sal watch­words for safer health­care. Cana­da already falls far short in pub­lic report­ing by its hos­pi­tals com­pared with the U.S.

The U.S. sys­tem has moved for­ward in anoth­er impor­tant way. Health­care experts there have begun to devel­op a list of “always” or “must do” events. Recent­ly, for instance, the Boston-based Lucian Leape Insti­tute of the Nation­al Patient Safe­ty Foun­da­tion, a world-renowned patient safe­ty orga­ni­za­tion, rec­om­mend­ed that per­form­ing hand hygiene before and after patient con­tact be made manda­to­ry and clas­si­fied as a “must do” for all health­care work­ers.

Cana­da is not even close to devel­op­ing that kind of approach, despite hav­ing an infec­tion con­trol rate in its hos­pi­tals that is one of the worst in the indus­tri­al­ized world

As part of its con­sul­ta­tion process lead­ing up to the final report, the authors invit­ed select­ed groups to com­plete an on-line sur­vey. Some 158 groups and orga­ni­za­tions respond­ed. Eighty-five per­cent were health­care pro­fes­sion­als and admin­is­tra­tors. The report does not say if any patients and fam­i­lies respond­ed to the sur­vey.

My expe­ri­ence is that patients and fam­i­lies who have been harmed by med­ical errors in the hos­pi­tal set­ting have a lot to offer about what needs to be done to make the sys­tem safer. Many are espe­cial­ly artic­u­late about the emo­tion­al harm their expe­ri­ence caused. I hear from them every day. It would have been help­ful to see their input more promi­nent­ly reflect­ed in this report.

Some­thing else the report left out: the stark real­i­ty that in Cana­da, hos­pi­tal errors are the third lead­ing cause of death. That means they claim more lives than strokes, Alzheimer’s, kid­ney dis­ease, breast can­cer and train, air­line and auto­mo­bile acci­dents com­bined.

Patients and fam­i­lies are look­ing for real answers about what will be done to make their hos­pi­tal stay safer. Unfor­tu­nate­ly, Canada’s nev­er list, slow to emerge in the first place, miss­es the mark in giv­ing patients and fam­i­lies the pro­tec­tion they need.