After the Error recounts positive changes in the wake of medical mistakes

    1 of 2 2 of 2

      Working as a B.C. coroner for 10 years, from 1993 to 2003, Susan McIver became well-acquainted with death. Over the phone from her home in Summerland, McIver emphasizes to the Straight that coroners don’t find fault—they merely report the facts. But that doesn’t mean they aren’t troubled by some of their grisly discoveries.

      “I saw things happen that shouldn’t happen,” she concedes.

      In one instance while working in the Okanagan, she was approached by a woman whose son had died under questionable circumstances in another part of the province. That led McIver, a microbiologist and former University of Toronto medical professor, to become keenly interested in preventable mistakes in health care. This led to the publication of her first book, Medical Nightmares: The Human Face of Errors, in 2001.

      More recently, McIver and retired registered nurse Robin Wyndham wrote a follow-up, After the Error: Speaking Out About Patient Safety to Save Lives (ECW Press). It demonstrates how patients who’ve experienced serious medical screwups and their family members have overcome their grief and outrage to bring about positive changes to the Canadian health-care system.

      “There’s nothing more powerful than people telling other people their stories,” McIver says.

      Five of the tales involve people from B.C. One of the most compelling is about Catherine Adamson, whose 17-year-old daughter Heidi Klompass died as a result of complications from treatment after being struck by a motor vehicle in 1997. Adamson wrote a book to educate medical practitioners about how her daughter suffered an embolism in the brain, which caused significant damage, along with questionable treatments that hastened her death. According to McIver, Adamson visited Vancouver-area hospitals and left copies in doctors’ and nurses’ lounges.

      McIver explains that as a result of Adamson’s efforts, it’s customary for surgeons to prescribe anti-clotting medication to orthopedic patients. “That book is in various libraries for the UBC faculty of medicine,” she adds.

      Another riveting tale, which is told over two chapters in After the Error, concerns a retired RCMP investigator, Gordon Nixon, and his wife, Rhonda. She suffered a perforated duodenum (in the small bowel) and common bile duct after laparoscopic surgery to remove her gallbladder. Nixon used his investigative skills—which included obtaining billing records from the Medical Services Plan—to corroborate key information and hold health-care officials accountable.

      After the Error also reveals how investments in hand-hygiene programs can save millions of dollars in health costs. That’s because hand-washing curtails the likelihood of infectious-disease transmission, reducing the amount of time some patients will spend in hospital.

      Coauthor Wyndham tells the Straight over the phone that there have been tremendous advances in the area of infection control, as well as in providing information to patients’ families. She recalls seeing a pamphlet not very long ago in a Penticton hospital telling people not to be afraid to ask questions of the nurses. That would have been unheard-of many years ago.

      “It used to be that the doctor said ‘this’—and that was the word of God—but not more,” Wyndham says.

      The book cites occupational health specialist William Charney’s 2012 estimate—which was printed in Canadian Dimension—that between 37,977 and 43,031 people die in Canada each year in connection with the delivery of health care. Charney arrived at that figure by combining findings in the Canadian Adverse Events Study, which was published in the Canadian Medical Association Journal, and the Public Health Agency of Canada’s data on fatalities from infections.

      “Are things getting better?” McIver asks. “That’s a very difficult thing to answer. Certainly, the awareness is increasing and there’s increasing endeavours to do something about them.”

      McIver emphasizes that not only are medical errors devastating for patients and their families, they can also leave lasting and damaging effects on health-care workers. “In the United States, people have left their positions as nurses and doctors,” she says. “[There are] even cases of suicide as a result of being associated in some way with the error.”

      The final chapter by lawyer John McKiggan reveals the long odds against patients who want to file malpractice suits against medical practitioners. He writes that of more than 4,000 lawsuits filed in Canada between 2005 and 2010, only two percent resulted in trial verdicts in favour of the patient.

      “In most of the reported medical malpractice decisions across Canada, judges and juries tend to favour the doctor’s word, unless there is clear evidence to support the patient’s version of events,” McKiggan writes. “It is important for patients to document the consent process by making notes of any discussions you have with your doctor before you undergo a medical procedure, particularly any discussion about the risks, benefits and alternatives of the medical procedure.”

      Comments

      We're now using Facebook for comments.

      1 Comments

      dr very concerned

      Apr 28, 2013 at 7:31am

      heidi compass case is grossly misrepresented
      there was no medical error what so ever
      she sustained simple uncomplicated minmaly displaced mid shaft tibial fractures which wer properly spinted immediately.
      these injuries occurred when she and two other teens were run over by a truck diven by a fellow inebriated classmate at graduation
      such fractures if they require surgery are operated 12 to 72 hrs post injury if or time is available
      plans were in place to commence surgery at 8 hr post injury
      just prior to surgery heidi was rendered unconscious by a massive shower of fat emboli from her tibial fractures which were so extensive that they caused pressure reversal in her heart allowing fat to bypass her lungs and thus go straight to her brain resulting in loss of consciousness

      CONTRARY TO WHAT IS SUGGESTED IN THE RUBBBISH WRITEN BY ADAMSON AND THE VERY UNEDUCATED CORONER THERE WAS NO MEDICAL ERROR AS DETERMINED BY A VARITY OF MEDICAL BODIES INC COLLEGE OF PHYSICIANS AND SURGEONS AND FURTHER TO THEIR INSUFFERABELY REDICULOUS CONCLUSION ANTI COAGULATION WAS NOT THEN NOR TO THIS DAY RECOMMENDED FOR PROPHYLAXIS OF FAT EMBOLI IT HAS NO EFFECT. FURTHER EARLIER SURGERY WOULD HAVE MADE HER FAT EMBOLI MUCH WORST. IF THE INITIAL SURGEON HAD BY SOME UNCALLED FOR AND SPECIAL AGREEMENT WITH ANAESTHESIA BEGUN SURGERY EARLIER THE FATTY STORM FROM THE MARROW WOULD HAVE OCCURED UNDER ANAESTHETIC AND WITH THE REAMING ND MANIPULATION OF THE FRACTURES HAVE UNDOUBTEDLY BEEN FAR WORST SHE WOULD AT THE VERY LEAST NOT HAVE AWOKEN FROM THE ANAESTHETIC. SUCH A PATH WOULD HAVE LEAD TO CRITICISM FORM COLLEAGUES AND PERHAPS LEGAL ACTION WHICH DID NOT OCCUR BECAUSE NO DR COULD OR WOULD CRITICIZE THE COURSE TAKEN BY THE INITIAL SURGEON.
      HAD THE INITIAL PROCEDURE GONE AHEAD NEWS HEADLINES WOULD ALMOST CERTAINLY HAVE READ DR NEEDLESSLY RUSHES UNSTABLE PT TO OR CREATING DEATH OR COMA.
      After initial ressucitation in the radiology dept heidi was transfered to a larger hospital, where nurosurgeons placed a tube from her brain to her abdomen to attempt to decrease brain pressure.
      2 days later her tibia were operated
      Very unfortunately approx two wks later she died of a carostrophic arterial bleed in her hospital bed when the breathing tube (tracheotomy)eroded into her inominate artery at the top of her heart.
      UNFORTINATE AND EXTREMELY UNLUCKY BUT TO BLAME THE ORTHOPEDIST IS OUTRAGEOUS