Healthcare Provider Stories
This is a collection of stories from healthcare providers.
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Tragedy leads Dr. Doug Cochrane on mission to improve patient safety
The death of a young girl at British Columbia's Children's Hospital back in 1997 spurred Dr. Doug Cochrane to rededicate his career to improved patient safety and the reduction of preventable errors in healthcare facilities across the country.
The child died two weeks after a potent anti-cancer drug meant to treat her leukemia was accidentally injected into her spinal fluid instead of into an intravenous drip. Cochrane, a pediatric neurosurgeon at Children's Hospital, was part of the medical team that fought in vain to reverse the effects of that error and save the girl's life.
"It was a profound event to have a patient succumb as a result of the best intended treatments but where those treatments had failed this patient," Cochrane recalls.
"As an organization, the Children's Hospital went through great, great deliberations. We had courageous leadership form Pat Evans, David Matheson and our CEO, Linda Cranston, who came forward and described what had happened to this child in a very public way. I think it was the first time that we as an organization had taken a responsibility for the consequences for our actions where those outcomes were tragic."
Cochrane, who today is the chair of the BC Patient Safety and Quality Council, in addition to serving as the Patient Safety and Quality Officer for the province, remembers the experience as an alarming wake-up call both for himself, as a cocksure physician, and for the hospital.
"As an organization we had no idea that there was the possibility of creating this kind of injury. We thought our systems were foolproof. We thought that we had systems that were resilient and rigorous and we had people in whom we had absolute, and continue to have absolute, committed trust. And yet the system failed the patient. The system failed the organization. The system failed those individuals who were treating that patient."
In the aftermath of the little girl's death and the discovery of similar cases across North America, the Children's Hospital implemented a number of new safety measures, including changes to drug labelling. Meanwhile, Cochrane was undergoing a personal transformation of his own.
"For me it took me from the enthusiastic trainee who I guess had — well I'll be really honest — the arrogance to think that whatever we did was the right thing to do, and whenever we had patients who had poor outcomes it was usually because of what the patient had brought to the situation, to the sudden realization that actually what we did mattered in very concrete ways. How we organized what we did, how we paid attention to what we were doing. And as an individual, that has had a profound effect on the way my career has unfolded and the interests I've developed in the patient safety and quality world since that time."
It is sometimes said that modern medicine is burdened with an unfair expectation of perfection. Patients certainly have an understandable need to consider their doctors infallible. Cochrane brings an interesting perspective to the matter.
"The idea that mistakes can't happen in our healthcare system is not too far from the truth. When you think about how many successful interventions, how much is happening in community care or long-term care to keep people safe, people that are being rescued from illnesses that would have taken their lives 10 or 15 years ago … it really is quite amazing what people and teams and organizations can do.
"But we would be blind to ignore the fact that we are human and that mistakes happen. They happen because we are human and because of the way we think and the way we act and who we are and I don't think we can necessarily make systems mistake-proof, I just hope we can make systems that will catch the mistake before they do harm."
Cochrane is of the belief that most healthcare workers acknowledge errors quite freely; they just don't always do it in a public way that can help relieve them of the emotional trauma that sometimes only further undermines effective patient care. Many of those people — nurses, physicians and other clinicians — are confronting those mistakes in sleepless nights or heightened stress and anxiety at work and at home, he says.
"The impact of errors that have occurred, particularly when they occur by your own hand, is profound. It does wake you up in the middle of the night, you do ask questions about your capability, your competence: 'Can we do this? Can I come back and do this again tomorrow?' And I suspect there is process that people have to work through to incorporate what really is a grieving loss process. It's not only a loss in the relationship with the patient but it's a loss in self-confidence and understanding.
"I think one of the things I have learned is that you somehow need to have an organization that is sensitive to this. Because I would never ask for help. I might be pushed to find help, probably by my wife, but I would never ask. But what would make a difference is that a colleague comes up and says, 'tell me about what happened and tell me how I can help you.'"
Whenever possible, part of that healing process should include a face-to-face disclosure of the mistake to the patient or family, Cochrane adds. That's a conviction he's held since even before his experience with that little girl whose life could not be rescued.
"This was not the first event in my career where I've had the opportunity to recognize my own weaknesses, or my own limitations, and a system that wasn't on top of things. I can think of several examples where the comfort that it brought to me to be able to acknowledge this with the family, or with the patient, was tremendous," Cochrane says.
"I don't think it made it any easier at all for the family, it didn't make it any easier at all for the patient, and it didn't make it easier for me, but it made it different and it brought us to an eventual understanding of our respective roles and — in my circumstance I'm thinking of a particular example — where we could have been better, and we weren't. And that was the royal 'we' — me."
As a former chair of the Canadian Patient Safety Institute (now Healthcare Excellence Canada), Cochrane understands the value and immediacy of individual stories in the campaign to raise awareness for improving patient care.
"I wanted to share this story because it is such a profound story at so many levels. Clearly the most significant level is in the lives of the family and in the life lost in that child. But it's not just there. Children's Hospital is a different organization because of that experience. Children's Hospital takes care of its patients differently now in a way that is safer. Children's Hospital organizes and cares for its staff in a way that is different and is safer. And we've taken the approach to communicate our experiences and results to other individuals and organizations less they assume they would never be subject to such an event or such an error. And I think that's actually the marvellous opportunity that has come out of this absolute tragedy."
Cochrane hopes every new generation of healthcare providers comes into the system a little better prepared than their predecessors in understanding the strengths of health care as well as its limitations. He's encouraged by what he sees.
"I'm amazed at the current set of trainees that I'm exposed to on a day-to-day. They truly up my game. Because they're far better prepared and have a far better working knowledge of many aspects that relate to safe care. They are more insightful about themselves, they are more understanding of their own reactions, but they are also more understanding of patients and how to treat them and families in a way that is respectful. I think we are in a good position but I would want all of them to remember that we have an obligation. We're fortunate in Canada to have a system in which we have an obligation, not just as taxpayers but as providers, and that obligation is to make the system better and to make it safer for all."
Dr. Doug Cochrane passed away peacefully at home, surrounded by his loving family, on February 17, 2024. Dr. Cochrane's exceptional contributions to education and unwavering commitment to advancing patient safety set a benchmark for excellence. His exemplary leadership and dedication to advancing healthcare quality have been an inspiration to many in British Columbia and across the country.
Dr. Francois deWet turns “physician’s worst nightmare” into opportunity for improvement
The lady presenting to the emergency room that evening seemed like countless others for Dr. Francois deWet until a life-changing moment he will never forget.
She had been brought into the small rural Newfoundland hospital where deWet was working by family members, who reported that she had been suffering chest pains since earlier in the day. The patient hadn't been seen by any doctors since being admitted to the hospital some 14 years earlier following a suicide attempt. She had been unwell for several weeks and her family suspected she had diabetes, but until that day had steadfastly refused to see a physician.
An electrocardiogram confirmed that she'd suffered a heart attack. She was treated according to their protocols and initially seemed to stabilize but her condition then rapidly deteriorated. She became short of breath and the oxygen levels were dropping.
"I made a decision at that time to put a tube in her, to intubate her, because we were afraid we were going to lose our airway," deWet recalls of the case. "The two nurses working that night were two of our senior nurses. I had complete confidence in them and they had complete confidence in me."
DeWet turned to one of the nurses and asked for "scoline," short-term slang for succinylcholine, a standard medication that relaxes the muscles to allow doctors to put a breathing tube down a patient's trachea.
"The nurse looked at me and she said, 'scopolamine?' Which is another medication we use in palliative care to dry up secretions. I, of course heard 'scoline' and I said 'yes, scoline.' So she ran off, got the medication and by the time she came back I'd decided we had to intubate," deWet says.
"We gave her the medication and nothing happened. I was confused for a few seconds because this was not the way it was supposed to be. She was supposed to relax immediately for me to intubate. I was running through my mind what the reason could be why this drug was not working. But it was almost like I couldn't think in that critical situation. I was looking at the monitor and I was seeing that the saturations was getting lower and I said, give another dose. The nurse immediately gave a second dose and again nothing happened."
Confounded, deWet wondered if something was wrong with the medication or if perhaps the patient was somehow not susceptible to it. He had never seen anything like this before in his entire career. He asked for rocuronium, another medication of the same type. The patient was given that drug, she immediately relaxed and deWet and his nursing team intubated her.
A long resuscitation attempt followed, but in the end the woman could not be saved. DeWet broke the news to the family and tried to comfort them. They asked to spend some time alone with their loved one.
"I went outside and I was sitting at the nursing station and we were just talking about what happened … And the nurse said to me, 'You know, I've never seen scopolamine given in a code.' And as soon as she said it, the penny dropped.
"You have this feeling in the stomach. It's between when your wife says, 'honey, we need to talk,' and your secretary calls and says "Revenue Canada is on the phone looking for you.' It was just like someone had punched me in the stomach. And immediately I knew that that's what happened. We had given the wrong medication during the intubation process. And my mind started running because now I'm thinking did that contribute to her death, was this something that could be avoided, is this maybe why we couldn't resuscitate? At that time I didn't understand how or if this drug could have contributed or not contributed to the situation."
In that moment deWet was confronting every physician's worst nightmare — a preventable medical error. He didn't know if the drug mix-up had contributed in any way to his patient's demise but he knew that a mistake had been made. He also knew that the first thing he had to do was tell the family. He pulled the patient's sister aside and told her what had happened, saying he didn't know if the mix-up had contributed to the death, but vowing to find out quickly and let her know. The woman took the disclosure with remarkable reserve, deWet says.
The incident triggered waves of emotional turmoil among all the medical personnel involved, deWet recalls. The nurse who had administered the medication was tremendously distraught, because she felt at fault. DeWet blamed himself for using a slang term for medication she might not have been familiar with. Everyone felt that they had somehow failed in delivering the best care possible to that one patient.
That evening, deWet contacted an internal medicine specialist and was given some assurance that the medication mix-up was unlikely to have contributed to the woman's death. Despite this, he and his nurses still went home the next day "feeling absolutely terrible." Part of the apprehension was tied to the realities of life in a small town, where everyone knows everyone, and the fear about how the incident would be perceived around the community.
When deWet met again with the family the following day, they were "amazing" in their understanding. The sister had already reached out to one of his nurses to assure her that they understood and they knew that it was a mistake.
"I think that they knew that whatever had happened was not something that was purposeful or something that had malignant intent. And I think they were very supportive."
That compassion, as well as the support of his wife, a nurse herself, and his colleagues helped console deWet through some painful second-guessing, and many sleepless nights. But only to a point, he says.
"It's like this. Even though other people will say to you that you did okay, or we're fine with it, there's that inner voice that just kind of screams at you the whole time, saying this was wrong, this shouldn't have happened, you did wrong and you're a failure at what you did, and you have to listen to that 24/7."
Looking back, deWet recalls the emotional trauma he struggled with as a practicing physician with some 20 years' experience and wonders how much greater the strain must be for health care providers who are still relatively new to the system. He's not surprised that the literature shows that such adverse episodes can be career-ending moments for many young health professionals.
"There are two ways that people can approach an incident like this. The one is the old-style circling of the wagons and the cult of silence, where I won't tell if you don't tell. But that's the wrong way of doing things. That's the old way of doing things. What should happen in these cases is that it should be assessed, it should be evaluated, it should be looked at and it should be picked apart, and the cause of what happened should be found and it should be dealt with. Because if it's happened once, it will happen again and if we don't fix these things as they come up, what will happen is someone else will be harmed in the same way and same manner."
DeWet and his nurses made the immediate commitment that fateful night to be fully open about the incident and work towards a full quality review of what happened. As a result of that specific incident the hospital had changed procedures in administering medications in resuscitation situations, including the storage of drugs and the specific naming of drugs requested by medical personnel.
"It's been almost three years since this has happened and I still see the family around town, I still see them in the hospital and some of them are my patients. And every time I see them my initial reaction is still kind of like a shimmering of fear and shame in the back of my mind. But I also look at them and can hold my head up high and say whatever happened that night, something good came out of it. And I think they know it."
Near-fatal medication error leads nurse to make patient safety a priority
More than 30 years have passed since the near-fatal medication error but Michael Villeneuve recalls the moment with absolute clarity.
The little man on his shoulder was telling him 'wait a second, something is not right here,' but Villeneuve, then a cocky young nurse eager to keep pace with his colleagues in an Ontario intensive care unit, went ahead and administered the medication.
The instant he did so, he knew exactly what he'd done: right drug, wrong patient.
Now the chief executive officer at the Canadian Nurses Association, Villeneuve frequently draws upon that experience in his day-to-day work to promote better care, better health and better nursing across the country.
As a youngster, Villeneuve always dreamed of becoming a surgeon. His grandmother was a director of nursing in a small rural hospital and used to take him by the hand and lead him, spellbound, along with her as she did her rounds. His ambitions shifted slightly in high school after a family friend helped him get a job as an orderly at an Ottawa hospital. He was there less than an hour before he realized he was far more fascinated by what the nurses were doing than the doctors.
"There was something about the competence of those women," Villeneuve recalls. "If you've been in an emergency department with certain women running the place, there's a kind of swagger and an attitude that's quite intoxicating when you're young. I just thought, 'I want to be like that.' That's where I ended up working in emergency intensive care, neurosurgery and so on, and never looked back. To this day, I would never change a second of it.
"Except I wouldn't make the mistake."
The mistake happened back in 1985. Two years after graduating nursing school Villeneuve had moved from a ward setting into a neurosurgical intensive care unit. He'd only been there a few weeks. At that time in the profession a male nurse was still something of a novelty and Villeneuve was eager to prove his worth. In that setting, an open ward with 12 beds, the pace is fast. Villeneuve remembers being so impressed by the confident execution and rapid thinking of the nurses around him.
"When I think back to what happened, I do think some of it was trying to be better, faster maybe than I was, if you know what I mean."
On the day of the incident, Villeneuve had two patients in his care — one with high potassium levels, the other with low potassium. The charge nurse took a call from a doctor, directing potassium be administered to one of his patients. She transcribed the order, called Villeneuve over and holding up the order sheet, instructed him to give medication A to patient B.
It is something in that chain of events, a partially obscured order sheet, the utterance of one patient's name rather than the other, that sent Villeneuve to the wrong bedside.
"I took the medication, which I had drawn up, potassium, and was about to give it to the patient and — this was a big lesson for me in my entire career — I thought, something was wrong," Villeneuve says.
"I thought something was triggering me, something's wrong with this. What I didn't do was stop. I pushed it in, slowly, but pushed it in. It wasn't two seconds after I finished that I thought, oh, it's the wrong patient; it's the guy with the high potassium that I just overdosed with a whole bunch more potassium. Literally I nearly collapsed. I thought, my career's over, I'm going to lose my license, he's going to die."
Villeneuve owned up to the error immediately and nurses and doctors swept in to attend to the patient, whose heart went into immediate distress. To make matters even worse, the patient was a senior physician himself. Villeneuve was so upset that his colleagues basically parked him in an adjacent staff lounge for the remainder of the day.
"It's 32 or 33 years ago that that happened and it is still cemented in my mind, everything about the lighting in that room that day, the look of people around me, how I felt, what I learned about when the little man on your shoulder says, 'Slow down,' you should slow down before you hurt somebody," Villeneuve says.
He views his experience as a perfect example of what is confirmed so often in medicine and nursing, which is that errors most often happen at points of handoff in care.
"We see it in handoffs even in home care from registered nurses who provide plans of care and delegate care to a licensed practical nurse who may delegate that to a nursing assistant or a personal support worker and, a point of great error, onto families," Villeneuve says.
"Because families provide a lot of care. So it's not just a critical care unit issue or a hospital issue; it's across the healthcare system. Points of handoff, and the more of them there are, the more chances that there are for an error."
Villeneuve spent an entire second shift in that staff lounge that fateful day, panic-stricken about his patient, worried about his future, wracked by that "terrible fear of error" that hangs over nursing from graduation day onwards. But as the hours passed it eventually became clear the patient would survive. It was only then that Villeneuve had a chance to talk things over with his head nurse, who was wonderfully supportive.
"I was expecting when she came in that I might be disciplined, I might be sent home. Her comment was, 'What did you learn?' " Villeneuve recalls, choking up at the memory.
"She said, 'slow down.' One of the nurses I really looked up to was a nurse named Jennifer who was so competent. And she said, 'You're not Jennifer yet. Settle down. Stop. Double check.' All the things I knew I should've done. And it helped me reduce my ego, which was quite constrained after that incident."
It was a major life lesson for him. When that little man on your shoulder says stop, it's like encountering the yellow light at the intersection. You shouldn't speed up, you should slow it down.
Even now in my administrative roles, my teaching roles, if I sense something's wrong, I just say to people, 'I need a day to think about that.' I try to not make snap decisions and I think my decisions are better."
David U fights for a blame-free culture in healthcare
David U was first struck by the tragic ripple effect of medication errors back in 2003.
The president and CEO of the Institute for Safe Medication Practices Canada (ISMP - Canada) had been called as an expert witness for a coroner's inquest into the death of a hospital patient. The death occurred after a nurse mistakenly flushed the patient's intravenous line with concentrated potassium chloride — a chemical used in lethal injections — rather than the intended normal saline. At the time the two solutions were stored and dispensed in almost identical vials in healthcare facilities across the country.
A pharmacist with more than 40 years of experience, U remembers staying up late one evening at his Ontario home to prepare for his testimony the following day. As he pored over the case reviews and investigative reports filed in the aftermath of the death, including the account of one deeply traumatized nurse, he was deeply moved.
"I remember all the boxes of stuff in my little study in my house," U says. "Everyone, my kids and my wife, were already asleep and it was just so sad, the fact that all these things happened. I could see that this was not the nurse's performance issue, or any mistake on her own. I just couldn't help the tears coming to my eyes when I looked at all those documents.
"It told me I had to do something about it. I did do something about it and hopefully this will never happen again, and so far so good."
When U founded ISMP Canada back in 2000, the culture surrounding healthcare-associated harm in Canadian hospitals was still very much one of finger-pointing and blame. Most experienced nurses, physicians and other clinicians have been associated, in some way, with such adverse events but yet at that moment the incident occurs the health provider closest to it can often feel quite alone.
U cites the case of another fatal healthcare mishap that involved the correct medication but the wrong administration. A young cancer patient needing chemotherapy was hooked up to a mobile infusion pump that should have been set to administer the highly toxic drug over four days. Instead the chemo drug was infused over four hours and as a result the woman died almost immediately.
In that case the nurse involved did meet with the patient's family afterwards in an attempt for all parties to grieve and heal together, U recalls.
"In both those cases I didn't see that the family held a big grudge against the provider, which is a good thing. I think we all know they are actually the second victim. I think in both cases the nurses left their profession, and that's also very, very traumatic."
U's organization has made great strides in recent years in the battle to reduce preventable medication errors like those that continue to stick in his mind today. Steps have been taken to restrict the availability of potassium chloride ampules that previously were widely accessible in hospital wards across Canada. The institute has worked alongside Health Canada to press manufacturers on drug package design so that products such as potassium chloride concentrate are clearly distinguishable from other medication.
ISMP Canada has also waged a campaign to reduce the risk of hospital errors involving the anti-cancer drug vincristine following a number of tragic mishaps where the medication was injected into a patient's spinal fluid instead of into an intravenous drip. It has also pushed for a national plan to roll out bar coding for medication throughout the country as a step toward standardizing the delivery of that medication and reducing the chance of human error. U is proud of the support and discretion that his organization provides to health care workers across the country who report errors.
"One of the things that we do and do well is to connect with providers, the actual staff, nurses, pharmacists or even physicians who contact us, either through phone or email or our reporting program, to tell us their story," U says. "And again we keep that information confidential, encourage them to talk to me or ISMP Canada, and then we will use their information to try and correct the system.
"That is also their goal. The only reason they're calling me is out of altruism, they want to share this story so that nothing of this kind will happen again."
Everyone is human, no system is infallible and errors will happen, U says.
"I think this kind of support, a personal call and reassurance that we can do something about it, goes a long away. Nothing goes into a black hole from the provider's perspective because that's what they want. They want changes, they want support."
While nobody in healthcare goes into work wanting to make a mistake, acknowledging those mistakes when they occur, however difficult that might be, is best for everyone.
"Whatever you need to do, tell yourself that you have done your best and try to report it, and collectively we can make sure of change," U says. "And don't be afraid."
Patient’s unexpected death changes the way one obstetrician thinks all doctors should be educated
Shocked, bewildered and angry, Dr. Amy Nakajima pored over her medical notes, trying to coax from them some sense of the bloody chaos she'd just experienced.
Earlier in the day, a healthy and expectant young mother had come in for a routine delivery at the Saskatchewan hospital where Nakajima worked. It was 2001 and Nakajima was just 14 months into her practice as an obstetrician-gynecologist.
Nakajima had been called in to assist just as the woman was pushing because the baby's heart rate seemed to be dipping. A vacuum procedure went well, a healthy baby was delivered, but the woman was bleeding a bit afterwards. Nakajima repaired a tear in the vagina but the bleeding didn't stop.
"We worked on that, and still she continued to bleed," Nakajima says, recalling a day that altered the course of her career.
"I called my second on-call in to give me a hand and then the anesthesiologist said that he was struggling too. So he called a second anesthetist to come in and help. Then, it became clear that we were having trouble even accessing IV lines. So the general surgeon came in to do a cut down.
"It had started with what appeared to be a fairly routine case, then it started drifting into 'this doesn't feel right; this isn't working; she's not responding in the way I'm expecting her to respond. We're all struggling now. It's not just me. The entire team, every set of providers, we're all struggling. It felt ... we all felt, I think, at a loss."
It descended into a scene of controlled confusion, with everyone doing what they've been trained to do, everyone doing the right thing to make things better, and yet getting no results. They managed to stabilize the patient enough to transfer her to the ICU, where, she shortly coded and died. At that moment, for the entire medical team, there was an immense sense of unreality, Nakajima says.
"It was a horrible event. It was traumatic for everyone. Of course, primarily for the family. But it left such a mark on the entire team. I think just hearing that story, you can imagine how I might feel, but the guilt and the shame that come with that event, I think is really unknowable until you have encountered it yourself."
When she called the hospital's chief of staff and told him what had happened, his response was disbelief. They hadn't lost a mom in decades. Nakajima informed him she was scheduled to be on call for the entire weekend but she'd need a replacement to cover for the remainder of her call and would stay on call until her replacement arrived the next morning. She was absolutely drained and felt so shattered she didn't feel safe to work.
Nakajima took two weeks off work. She had told herself that if the autopsy didn't turn up embolus or some other rare cause, she would quit her young career. She knew that the medical team should have otherwise been able to save that patient.
In the end it was determined the woman had suffered an amniotic fluid embolism, a rare and usually fatal obstetric emergency that occurs when amniotic fluid enters a mother's blood stream and triggers a catastrophic, allergic-like reaction.
"I attended her funeral. It was amazing. I don't think I'll forget that, ever. It was completely full. I felt so sorry for this family," Nakajima recalls. "I came back to work two weeks later and I'd come back to a hospital where I'd lost a patient, and not one word of blame. Incredible support everywhere I turned. So, in hindsight, now knowing what other second victims encounter and endure, I feel so very fortunate for having had that support and that amount of compassion shown to me."
The experience marked her in many ways, Nakajima says. The helplessness and frustration she encountered that day, feeling so entirely unprepared to go out to that young father and tell him that his wife was dead and his children orphaned. She doesn't know the person she would have become had this not happened to her, Nakajima says. This event early in a fledgling career in many ways informed her choice of practice, the way she interacts with her patients and colleagues, and the way in which she teaches.
Nakajima provides care at Wabano Centre for Aboriginal Health, within the Family Health Team at Bruyere, and at St. Vincent's Hospital, with a specific interest in working with patients who traditionally would be considered marginalized. In her teachings with third year medical students at the University of Ottawa, she stresses patient safety, candid communication and the importance of acknowledging harm. She promotes the use of simulation to explore and teach safety issues, including disclosure skills. As the interim Director of Research and Development of SIM-one, the non-profit healthcare simulation network, she will be developing programs on ways to use simulation to advance patient safety.
"It is such a challenging discussion to have with a family, to say, 'I'm really sorry, we couldn't save your mother," she says. "Some people have made a parallel to breaking bad news curriculum in undergraduate medical education, but I think it's fundamentally different. In breaking bad news, I could say, 'I'm really sorry, remember the tests that we did last time? It shows that you have cervical cancer.' It's terrible news for a patient. I will feel terrible giving that news to her because I know what's coming. But that's fundamentally different from me saying, 'I'm really sorry, you have breast cancer; we removed the wrong breast."
Says Nakajima, "It is a very different conversation because you now have to take ownership of your participation in the harm that came to this patient through healthcare. I think this needs to be part of undergraduate education and postgraduate education. And we need to consider how to most effectively and impactfully deliver this curriculum, so our students are thinking of how to optimize safety, and are better prepared when bad things happen."
Surgical error inspires doctor to champion the safety of all patients
Dr. Peter Pisters is President & CEO of University Health Network (UHN), an academic health sciences centre in Toronto. UHN is an integrated health, research and education system that includes four hospital sites, Toronto General Hospital, Toronto Western Hospital, the Princess Margaret Cancer Centre, Toronto Rehabilitation Institute, and a school, the Michener Institute of Education at UHN. But he also sees himself as UHN's Chief Patient Safety Officer.
That's a duty he takes very seriously, fuelled by the painful memory of a single surgical sponge left behind in one of his patients.
It happened more than a decade ago, when Pisters was working as a busy surgeon at the University of Texas MD Anderson Cancer Center in Houston, but the feelings of fear, anger and frustration he felt that day remain fresh in his mind.
Pisters was leading what he describes as a highly complicated operation where a patient's diseased esophagus was removed and replaced with a transplanted segment of their colon. The surgery involved multiple teams and the procedure took nine hours to complete. Everything went well, but as the surgical team was finishing the standard sponge count, conducted before and after surgery, they came up one item short. Surgical sponges are squares of gauze used to sop up blood. During a long operation, doctors may use dozens of them inside a patient to control bleeding.
False counts are not uncommon in the bustle of an operating room, and Pisters ordered a recount. On that second check, it was believed that all sponges were accounted for.
"At that point in time the operation had been going on for a long time, the patient was cold, and I felt it was absolutely impossible that I could have left a sponge in the patient, and decided instead to let him go to the recovery room," Pisters recalls.
But there was still a trace of uncertainty in his mind. Just to be sure he ordered X-rays. When the images showed something had been left inside his patient, Pisters was stunned. Complicating matters, as he examined the scans, he found he could not identify with certainty what the item was.
"I realized at that moment that during my surgical training, during my fellowship training, in textbooks, in exams, I had never seen X-rays of foreign bodies that had been left inside patients. And as a result, I couldn't identify the foreign body, the material that I had left inside the patient."
Pisters immediately went to the patient's wife and told her something was not right, and that he suspected something had been left behind in her husband's body.
"As I left that first conversation I remember vividly walking down the hallway, with my head down thinking, 'how could this have happened, how am I going to figure this out, what am I going to do? What will this mean for me? Could this affect my family?" Pisters recalled.
"I had reached, in many ways, the pinnacle of my career. I'd been promoted to full professor after 10 years on the faculty. I was doing amazing, high-end technical surgery. We were experiencing incredible success as an organization in our group. And I was concerned that this would really adversely affect not just me personally and professionally, but would have wider implications on the organization. It could, in that environment, also extend into a world of litigation and a very complicated stream of events that's very unpleasant for everyone involved."
Over the next six hours, Pisters and his surgical fellows X-rayed every piece of equipment they had used in the operation that could possibly resemble the mystery object, until finally, at around 2 am, they concluded it was indeed a surgical sponge.
Pisters slept at the hospital that night and the next morning the patient was wheeled back into the operating room.
"I sat in the corner of the room on a stool and I watched my fellows re-open the abdomen. It took them just 20 minutes. They reached inside and pulled out the sponge. The whole thing was over in 30 minutes," he says.
"The patient was okay but that moment was like no other in my career. I felt horrible. I felt humiliated. I felt such grief. I could not believe that I could possibly commit an error like that. And as I began to think about this in greater detail, I began to realize that yes, I had committed an error, but multiple systems had failed this patient."
A surgeon made a mistake, two different sponge counts were done, and neither the physician nor the hospital had policies and protocols in place to deal with the conflicting information.
Pisters says he was personally changed by the experience and in later academic life, while studying patient safety at the Harvard School of Public Health, gained tremendous insights into the science of human error. When he moved into his leadership role at UHN in January 2015, Pisters saw it as a great opportunity to make a big difference in patient safety.
"Much of what we have to do today is to acknowledge and recognize that in health care we have had historically a culture of shame and blame, and a practice oftentimes of covering up our mistakes and moving on to the next patient," he says.
"We need to move past that, embrace principles and concepts of a just culture, and employ systems thinking to better understand the complexity of the work environment that we have in health care."
Pisters would like to see the Canadian health care system adopt safety approaches and principles that have been successfully deployed in other "high reliability" sectors like commercial aviation and chemical manufacturing.
"One of the biggest changes that we're bringing about at University Health Network is an approach that we call Caring Safely. It's a program that we have designed and rolled out in conjunction with the Sick Children's Hospital in Toronto. It really brings about a structured approach to patient safety, that begins with an effort to bring about a just culture, to bring about an approach that encourages a process of speaking up on safety, an approach that extends not only to patients but to employees and to workplace safety."
As the conversation around greater patient safety picks up steam across Canada, many health experts are pushing hospitals to become more open about reporting and publicly disclosing preventable errors. Pisters is one of them.
"I think patients and families do understand the complexity of medical care the way it's delivered today," he says. "They do understand that at times things don't go the way that we planned. And the candour and honesty that we demonstrate, even the uncertainty that we convey in times when we don't know, that in a paradoxical way builds trust with those patients and families."
Being involved in episodes of preventable medical error can take an emotional toll on health providers but Pisters believes the best remedy is for those providers to become safety champions within their own organizations.
"Those champions, especially when they are physicians, have tremendous influence in the health care environment in which they work. And when they move into leadership roles or they're fortunate to be in positions like mine, they can have profound influence on patient safety and this in turn can lead to saving thousands of lives."
Indeed, that's one of the reasons Pisters feels compelled to share his story. He thinks more health providers in the system need to stand up and be heard.
"All of us need to recognize that we have a role to play in patient safety and that we have an opportunity to create in Canada a transformational wave that really impacts how patients will be cared for in the future."
Dr. Julia Trahey calls for peer support networks to assist providers following patient safety incidents
For Dr. Julia Trahey, a shattering encounter 20 years back with one troubled young man carved a lasting division in both her life and medical career.
The experience also instilled in her a deep understanding of the burden that healthcare providers can feel after a patient is harmed. That's a special empathy the native Newfoundlander brings to her work every day as a general internal medicine specialist in St. John's.
"When I think about why I do what I do now, I go back to an episode that happened very early in my career, because there is a before and after of my career from that point," Trahey says. "It was a patient, a young man who was only a few years older than I was at the time, who had come in with a suicide attempt and had been transferred to the hospital I was working at for care because of respiratory difficulties that he had as a result of that."
After successfully reviving the man and working to stabilize his medical condition, Trahey remembers shuttling back and forth to emergency throughout a typically long and busy shift at the hospital. The patient seemed to be doing well.
But then she received a call at about one in the morning saying the man had again attempted suicide while under care at the hospital. For the second time in 24 hours, Trahey was called in to attempt resuscitation on the same individual. This time it was a completed suicide.
"I continued on call and was called in a few hours later to try another resuscitation of another patient who had been found dead at home, and then there were other patients throughout that night that I was dealing with. It was myself and the junior intern who was with me, and we were meeting with some of the family members, and it was a very, very traumatic event for the hospital, for the nursing staff, for the emergency physicians. Trying to deal with that and then going on with the rest of the work that had to be done throughout the night — you go into a state of kind of suspended not-feeling-anything. Work to do, just keep going, don't think about it."
Soon enough, though, the emotional trauma hit home.
"I know the next morning when I was coming off call, and I knew that there were going to further meetings about this, but I didn't know what to feel. I remember driving away from the hospital and ordinarily I would go to my mother and talk to her about this, but my mom and dad were out of town that particular day, so I went to my eldest sister's house. And I remember running a red light on the way there. And I just realized it after I went through, because I was just so — I don't even know how to put it into words. I didn't know what to think, it was just a jumble of thoughts, a jumble of thoughts and a lack of feeling because I didn't know what to feel."
She just needed someone to talk to. She'd needed someone to talk to back at the hospital, of course, but Trahey had wanted to be steadfast for her intern and besides, her other fellow physicians had seemed more matter of fact about her experience. A part of her also felt that, as a female, if she became too emotional it might be seen as somehow less professional on her part.
Still, an encounter with healthcare-associated harm can be an intrinsic hit to who you are as a health care professional, Trahey says, and also how you see yourself as an individual.
"I think certainly for those physicians of my generation and older, we were trained to feel that what we did and the outcomes for our patients reflected on some level how good we were as a person," she says. "Our professional role and our personal roles were so intertwined that when things go wrong there was little defense against feeling that somehow you failed as a human being, and not just in your professional role."
That view is changing and Trahey has been doing her part over the years to aid that shift in thinking. She's clinical head of patient safety at her organization and she's worked to ensure patient safety is a priority in the training of the next generation of Canada's health professionals. Ask her if there's one thing she would change about her experience with that patient years ago, and she responds quickly:
"If there is one thing I would change it's actually what I have chosen to change, and that is introducing patient safety into the undergraduate curriculum at our university" Trahey says.
"As part of that I have spoken about the need for a peer support network and that there should be no shame or apprehension about talking about errors, and that the likelihood of making errors is pretty much a given. Now they may not be errors that have catastrophic outcomes, but they need to be comfortable and accepted as normal as part of doing a high-risk business and also normal to talk about it. So, I've been encouraging them, and teaching them, that that's part of being a doctor."
The young man's death that day exposed collaborative flaws in the way that particular hospital dealt with patients with psychiatric and medical illness. In its aftermath, a new psychiatric liaison service was created to give all patients real-time access to psychiatric treatment. To this day, Trahey views that service as a tremendous positive for both patients and their physicians that arose from something that was otherwise so terribly negative.
That one life achieved a service that has helped hundreds of patients in the intervening years, she says.
"I think about the English language and how we use certain words — sorrow, grief, stoic — and I've seen that. I've been there in the room when it's been manifest, when people have been stoic in the face of horrible news, I've seen what sorrow is because it fills the room. I've seen and felt grief because you're there with people who have had really bad things happen.
"With that particular patient I did not have a long relationship. This was a very short duration experience, but it marked my career from before and after because of how I felt things could have been done differently that may have made a difference. That's how it's impacted me, then, now and why I try to do the work I do in the way that I do it."
If sharing her experience helps reduce the burden of emotional trauma for some health care providers out there, all the better, Trahey says.
"I'm at an interesting point in my career. I'm heading into the final phase. I'm not a junior doctor, I'm a senior doctor and I think it's important for other physicians and students to appreciate that these are the journeys that some people have taken through the course of their career. It can make you, I was going to say a better physician but it's not a better physician, it's a more aware physician. They will have their patients too that will change how they do business, and to embrace that as a learning experience and do something good with it. And I hope they get the support that they need from their peers."
Patient and Provider come together in wake of patient safety incident
Deborah Prowse and Steve Long might seem unlikely partners in the campaign to promote patient safety across Canada.
Prowse is the daughter of one of two patients who died in 2004 when a pharmacy at Calgary's Foothills Hospital mistakenly prepared dialysis solutions with potassium chloride instead of sodium chloride. Long was the director in charge of that pharmacy at the time.
It took two years before these two secondary victims of that great tragedy had a chance to meet in a healing face-to-face encounter, expressing sorrow, sharing grief and sowing the seeds for a remarkable advocacy alliance. Prowse and Long now appear together regularly, speaking with great candour about their shared painful experience.
The death of Prowse's 83-year-old mother Kathleen due to that medication error in March 2004 occurred at the end of a troubled 13 months of surgeries and setbacks that had already left the Prowse family highly frustrated over the state of her medical care. The shock of their mother's unexpected death left the family reeling, a trauma that only worsened amid the media firestorm that followed.
"My mom died as a result of a series of adverse events that led up to the ultimate event that took her life," Prowse says. "She'd had two medical stays in hospital and on both occasions there were things that did not go well."
For Long, the lasting memory is of a routine day gone horribly awry.
"The incident with Deb's mother occurred on a Friday afternoon. It was the same as any other Friday only the pharmacist that was working in the critical care unit came downstairs and said 'we've had a mix-up with the dialysate solution.' They'd taken it to the blood gas lab and they'd determined that there was potassium chloride in it."
Long and his team went back to their manufacturing records, checked the lot number of the bottle and discovered that batch of dialysis solution had in fact been mistakenly prepared with potassium chloride. At the time the potassium and sodium chloride were purchased from the same manufacturer, were stocked along the same row of shelves, and came in cases and containers similar in appearance. Even the colour and printing on the labels looked the same, Long says.
Later that evening, Long was helping coach his daughter's basketball team when his phone rang. His halting voice as he recalls that moment bears testament to painful memories he still carries with him today.
"The call was from the physician that was working in the ICU and he essentially stated 'you've killed my patient; what are you going to do about it and how are you going to ensure it never happens again?'
"I had been the director of pharmacy in Calgary for almost 20 years at that point. Never had I dealt directly with an error or an incident of this magnitude. We had recently opened a central pharmacy. We had designed it. We were aware of the quality and safety movement and how we could change processes to reduce the risk of error and yet here in this new facility that was designed to make patients safe we had done the ultimate damage. We had killed two patients."
The hospital and regional health authority implemented several investigations and qualitative reviews following the deaths, under the glare of intense public and political scrutiny. Over time the health region dedicated staff and resources to implement $7 million worth of patient safety initiatives. But in those early days, amid all that rigorous institutional self-examination, there was little support for the staff and family closest to the adverse event.
"Essentially we were just trying to cope with all the things that were going on in that immediate period, trying to understand ourselves what happened," Long says.
"Trying to keep the operation going because we still had 2,500 patients in hospital beds that required our due care and attention and expertise to prepare the products that they needed to make them well again. And yet we're doing it in this environment of distrust where everything that we prepared, everything we produced, was questioned, was challenged. Whereas before none of that had gone on.
"It was like being under siege. You didn't know what was going to happen, you didn't know how you were going to be dealt with. As a pharmacist with a license I didn't know whether I'd be able to practice after they'd determined what had gone on. So fear, disappointment, humiliation, failure — all of those thoughts were running through my mind as we were going through that immediate period."
Three technicians and a pharmacy assistant had been involved in the production of the fatal dialysis solution. Initially they continued to work at the hospital but as review followed review they were eventually sent home without pay, isolating them totally from their organization and any emotional support they might have found there, Long says.
For her part, Prowse came away from the entire experience with an iron determination to advance the voice and participation of patients and families in safety efforts across the country. Drawing on her mom's hospital odyssey, as well as her professional background and training in social work and law, Prowse became one of the a founding members of the Calgary Health Region's patient-family safety council and has since worked with Alberta Health Quality Council, Patients for Patients Safety Canada and many other such advocacy groups, including the World Health Organization's Alliance for Patient Safety.
"Patients and family members have to trust that their care is going to be of high quality and safe and when things go wrong, historically, there hasn't always been transparency and openness about admitting that," Prowse says. "And that is an affront to a trusting relationship.
"So it's very important that when things go wrong that there is disclosure of what happened. And the three parts of disclosure are the acknowledgement that something happened, the apology and then the action ensure that it doesn't happen again. Patients, I think, for the most part believe that healthcare providers come to work with good intentions and the desire to do well and to care for patients. Sometimes that doesn't go well. I think the greatest fear is that it will be covered up if something does go wrong."
Prowse and Long spoke about their experiences in a series of sessions targeting leaders in the Calgary Health Region during the roll-out of the new patient safety procedures, including new policies governing disclosure after harm, reporting, informing the public and a just and trusting culture within health facilities.
"That marked a huge change for patient safety in the province of Alberta and because of the national highlight that these events got it also started to change the conversation nationally about disclosure," Prowse points out.
"Now I think disclosure is much more thoughtfully done. My concern is that it still does not involve the people closest involved in all of the situations that it should. And I think that that is a big feature of healing for both the patients and the providers, is that we be brought together and allowed to go through those early stages of recovery close to the events, as soon as both parties are ready to do that. I think that's important."
That point is not lost on Long, who suffered a severe emotional toll following the deaths, as did his pharmacy staff involved.
"Pharmacy often is quoted in the literature as the invisible ingredient because it just magically appears up out of the basement, the drugs and the preparations, and most of the time it's correct … people get better. After the error and after credibility was lost, the one piece I never had closure on was we never had a chance to say we were sorry," Long says, struggling to maintain his composure.
"We had caused this great harm… We knew we'd done it and we didn't feel very good about it... "
If he has any message to health care providers who find themselves involved in adverse incidents, it's just to hang in there and get through it, Long says.
"Firstly, if you haven't had a medication error or if you haven't caused harm it's not because you're an exceptional provider; you've been lucky," he says. "Secondly, one of my biggest regrets is that I don't know that I checked in enough on my staff to see how they were doing to ensure they got the support they needed. And the third thing I'd say is make sure you take care of yourself. Take clues from family, from co-workers and others and seek help. I waited far too long before I sought professional help."
Prowse thinks her mother would be pleased by her advocacy work and the positive changes her death has triggered in patient safety. One of the things that has kept her going over the past 10 years is the number of health care providers who've come up to her after a speaking engagement and said how much her story has touched them, Prowse says.
"There's a saying that I think pertains to both of us," Prowse says, looking over at Long. "It's from Maya Angelou, something to the effect that over time they may forget the words you used but they will never forget the way they made you feel."