The story of Anthony Webb, lying in the University Hospital of Northern B.C. with liver cancer and mistakenly given a dose of morphine that put him in a coma for three days, should alarm all local residents, regardless of their current state of health.
As Christine Hinzmann's story in today's Citizen reveals, these kinds of events are common from coast to coast.
The Canadian Institute for Health Information, using data voluntarily submitted by hospitals and health authorities across the country, found that 5.6 per cent of patients were harmed by preventable, but unintended, conduct by their health-care providers in 2014-2015.
One in eight of those events resulted in death. Many of the harmful events were either medication mistakes, procedural errors or aggravated infections while some were patient accidents, such as a fall, while in hospital.
Meanwhile, Northern Health is refusing to supply their regional numbers, citing concerns about differing methods of reporting the results between health regions.
In Webb's case, both he, his family and the nurse were aware of the overdose almost immediately.
The morphine dosage may have killed him without the Narcan he was then given to reverse the effects.
That error profoundly affected Webb's confidence in the quality of the care he was receiving.
As his granddaughter Victoria Clarke told The Citizen, he literally feared for his life during his remaining time in the Prince George hospital and insisted on someone by his bedside 24 hours a day to guard him until he was finally discharged. He died two-and-a-half weeks later at the home of his best friend.
Both Webb and his family and friends were also fearful of kicking up too much of a fuss over the incident, not wanting to anger or upset the same people they were continuing to count on for health care.
It's important to stress that Clarke, a Prince George social worker, is not on some personal vendetta in the wake of her grandfather's death. During her interview with Hinzmann, she provided names of the supervisor and patient quality care officer but refused to give the nurse's name. Rightfully so, because this problem transcends human error and points to a systemic failure, as the national data show.
Northern Health's response to such events is frustrating but predictable. The health authority takes a passive "no blame, no shame" approach. In exchange for their honesty and transparency when mistakes are made, doctors and nurses are largely excused from immediate consequences in the aftermath of their errors. While there may be repercussions much later as the result of a formal internal review, that process happens behind the scenes, invisible to the public and to the affected patients and families.
That is in stark contrast to what happens when another group of individuals in uniform responsible for life-or-death decisions make mistakes. When someone dies or is seriously injured as the result of police conduct, the responsible officer is immediately suspended with pay and an independent investigator is brought in to review the situation. While this is certainly not a perfect response, either, it is far more hands-on, far more accountable and far more public.
Residents trust in the police but that trust does not extend to policing themselves, which is why the Independent Investigations Office was created in B.C. in the first place. By the same token, residents can have full confidence in their health care and still believe that doctors and nurses shouldn't be assessing each other's conduct when something goes wrong.
Perhaps the IIO should have a medical unit, made up of retired doctors, nurses and police officers to assess serious harmful events in hospitals and provide unbiased oversight. This is not to question the integrity of medical professionals but to boost public confidence in their work, since mistakes would be fully investigated.
As a result, patients would no longer be powerless. They could speak freely about harmful events they experienced to investigators. The way it stands right now, patients complaining about their quality of care while still lying in a hospital bed are as vulnerable as suspects objecting to the way they were treated during arrest while still in the back seat of a police cruiser.
Finally, independent review of harmful events would provide a reliable mechanism for the rare instances when health-care mistakes are criminal in nature, when the evidence uncovered by an outside investigation would warrant charges for negligence, for aggravated assault or for manslaughter.
Police officers conduct their duties under that level of scrutiny.
Doctors and nurses should be held to the same high standard.
-- Managing editor Neil Godbout
