We get a number of calls in our office from patients (or their family members) who have suffered injuries during their hospital admission which have caused them significant disabilities, or in some cases, death. How often does this occur and what causes these injuries? New reporting requirements in Ontario aim to shed light on this serious issue.
Hospitals in Ontario have been directed to report critical incidents involving medications and intravenous fluids to the Canadian Institute for Health Information National System for Incident Reporting. In issuing the directive, the Ontario Ministry of Health and Long-Term Care aims to minimize and prevent harmful medication incidents. The first annual report, issued in May of 2013, indicated that there were 36 critical incidents reported in that year. These critical incidents contributed to the death of 10 patients and left 26 patients with serious injuries.
What are the primary causes of these injuries to patients during hospitalization? The data reveals that the top medications that contributed to severe harm or deaths included opioids, heparin, norepinephrine and oxytocin. The factors that contributed to opioid overdose included pump or infusion rate issues, confusion over multiple dosage formats and knowledge deficits related to prescribing practices. In contrast, mix-ups involving oxytocin were due to similar looking packaging of IV bags and syringes being present in the obstetric suite. Other top contributing factors were communication, drug product confusions and distractions/frequent interruptions.
The results of this analysis have prompted the development of presentations and publications made available to health-care workers in Ontario. These educational efforts provide recommendations for system safeguards to prevent a recurrence of the problem and try to improve both the quantity and quality of the critical incident reporting.
According to the National Post, only Saskatchewan, Manitoba and Quebec have similar mandates for hospitals to report critical incidents, and Manitoba is the only other province that releases their results publicly.
The fact that only 36 critical incidents were reported over the course of one year may be due to under-reporting in this recently instituted program. It may also reflect the fact that although errors in health care occur from time to time, very few of them meet the criteria of a “critical incident” – that is to say very few result in death, or serious disability, injury or harm.
Read the full report here: Select
Read the National Post news article here: Select