CMAJ • October 12, 2004; 171 (8). doi:10.1503/cmaj.1040918.
© 2004 Canadian Medical Association or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters
Correspondance

Canadian Adverse Events Study

Ediriweera B.R. Desapriya

Department of Pediatrics, Centre for Community Child Health Research, Vancouver, BC

Ross Baker and associates1 adopt and reinforce a social intolerance toward AEs as events of innocent origin. In the complex environment of acute health care, it is very easy for errors to occur, and the health care system is well behind other high-risk industries in its attention to basic safety principles. Strategies to reduce clinical risk should not include punitive actions against those who have made mistakes, but rather action to change the systems in which the mistakes occurred.2 The key to reducing clinical errors is to make it difficult to do the wrong thing and easy to do the right thing.3

Making a profound change in the culture surrounding medical error and shifting the emphasis from silence to safety are the goals of a new program at Vancouver's St. Paul's Hospital, the only Canadian centre participating in a collaborative project of the Boston-based Institute for Healthcare Improvement.4 In the United Kingdom, "a mandatory no-name, no-blame national system for reporting ‘failures, mistakes and near misses’" was to be implemented in 2002 under the National Patient Safety Agency.5 It is now time to start evaluating the effects of these and similar programs in preventing medical errors. Furthermore, the results of such assessments should be widely disseminated for the benefit of patients in developing countries as well as those in developed countries.

Ediriweera B.R. Desapriya Department of Pediatrics Centre for Community Child Health Research Vancouver, BC

Footnotes

Competing interests: None declared.


References

  1. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004; 170 (11):1678-86.[Abstract/Free Full Text]
  2. Holbrook J. The criminalisation of fatal medical mistakes [editorial]. BMJ 2003;327:1118-9. [Free Full Text]
  3. Mission J. A review of clinical risk management. Qual Clin Pract 2001;4:131-4.
  4. Kent H. Talking about errors instead of hiding them goal of Vancouver hospital. CMAJ 2002; 166 (4):496.[Free Full Text]
  5. Sibbald B. Ending the blame game key to overcoming medical error. CMAJ 2001;165(8):1083.[Free Full Text]




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Right arrow Patient safety, clinical risk, medical error