1 in 18 patients experiences harm in Canadian hospitals

OTTAWA – A new report called “Measuring Patient Harm in Canadian Hospitals” reveals that in 2014–2015, harm was experienced by patients in 1 of every 18 hospital stays, or 138,000 hospitalizations. Of those, 30,000 (or 1 in 5) involved more than 1 form of harm.

Despite the high profile of medical error and patient safety issues in recent years, the rate (5.6%) has remained stable over the past three years.

The analysis of patient harm in acute care hospitals (outside Quebec) was developed jointly by the Canadian Institute for Health Information (CIHI) and the Canadian Patient Safety Institute (CPSI).

The report reflects a new approach in helping Canadian hospitals to measure and improve patient safety. The data reflects hospitalizations with at least one occurrence of unintended harm – harm that could possibly be prevented with the use of known, evidence-based practices. The harm must have occurred after admission and required treatment or extended the admission.

According to the report, on any given day more than 1,600 hospital beds across Canada are occupied by a patient who suffered harm that extended his or her hospital stay. In addition to what these patients and their families go through, their continued need for treatment also has a cost to the system, in that it keeps other people from getting the help they need.

“Health system leaders need timely, cost-effective solutions to measuring patient safety,” said Kathleen Morris (pictured), vice president of research and analysis at CIHI. “The new measure is based on existing data, making it practical to track improvement over time.”

Also launched by the partners was the Hospital Harm Improvement Resource, developed by CPSI to complement the new measure. This online compilation of resources provides evidence-based practices specific to the 31 different types of harm included in the measure and, as such, links measurement to improvement.

Together, the measure and improvement resource will serve as a new, readily available tool that hospitals can use to improve the safety of their patients and reduce the occurrence of harm.

The Hospital Harm Framework includes 4 major categories of harm:

• Healthcare or medication-associated conditions (e.g., pressure ulcers)
• Healthcare-associated infections (e.g., sepsis)
• Patient accidents (e.g., falls)
• Procedure-associated conditions (e.g., laceration/puncture).

Within each category is a series of individual clinical groups or types of harm, which connect to evidence-informed practices for improvement.

“With the improvement resource, patient safety teams and clinicians can now spend less time researching what to do, and more time planning and implementing changes that are known to work,” said Chris Power, CEO of CPSI.

When it comes to medication errors, the report said the three drug products most commonly involved with reported incidents are: Insulin, Hydromorphone hydrochloride, and Heparin. Moreover, many of the reported medication-related incidents involved “distractions or interruptions,” the most commonly reported contributing factor.

Overall, the five most common clinical groups, accounting for 51% of harmful events, are Electrolyte and Fluid Imbalance, Urinary Tract Infections, Delirium, Anemia/Hemorrhage and Pneumonia.

A small percentage of cases (<1%) are seen in Retained Foreign Body and Selected Serious Events. Many of these are never events – things that should not happen under any circumstances, that can lead to serious harm or death and that are completely preventable with proper checks and balances.

In 2015, the National Patient Safety Consortium prepared the report Never Events for Hospital Care in Canada. These events include operating on the wrong body part or unintentionally leaving a foreign object in a patient, among others. Many of these events will be captured as hospital harm. Some that are not related to clinical care, such as an infant who is abducted or discharged to the wrong person, are not captured in the measure.

It is important for hospitals to implement evidence-informed practices to prevent never events (such as counting tools at the end of surgery to ensure nothing has been left in a patient), as well as to monitor the effectiveness of those practices. However, hospitals must also take a balanced approach to improving safety. Focusing on this most serious subset of harmful events may mean hospitals are overlooking opportunities to prevent events that may be less serious but happen more frequently.

Ultimately, better patient care comes from continually working to promote a culture of safety at every level in a hospital or healthcare organization. Safety is improved by optimizing use of evidence-informed practices – practices that are known to reduce the occurrence of harmful events, such as pressure ulcers, infections or patient falls. While each hospital or healthcare organization works independently to improve safety, their work is supported by regulators, funders and provincial health quality organizations.

“While most patients experience safe care in Canada, we must continually strive to do better,” said the Honourable Jane Philpott, Minister of Health. “High-quality data is an important tool in assisting our improvement efforts, and we thank CIHI and CPSI for working together toward this goal.”

“One avoidable harmful event is one too many. HealthCareCAN welcomes the release of this report and working with CPSI and CIHI to pursue the common goal of quality and reliability for patients,” said Bill Tholl, CEO of HealthCareCAN, a national organization that speaks for Canada’s hospitals and works to foster informed and continuous improvement in healthcare.