McMaster University

McMaster University

Faculty of
Health Sciences

McMaster study to root out medical mistakes

Published: April 12 , 2007
James Paul
Dr. James Paul, assistant clinical professor and chair of research in the department of anesthesia at McMaster University and director of the Acute Pain Services at Hamilton Health Sciences.

The Canadian Institute for Health Information estimates as many as 23,750 Canadians die every year because of medical errors by doctors, hospitals and pharmacists.

Is it possible to get to the root of why this is happening?

Dr. James Paul, assistant clinical professor and chair of research in the department of anesthesia at McMaster University and director of the Acute Pain Services at Hamilton Health Sciences (HHS), thinks he may turn up some much-needed answers in a three-year study which he now has underway.

As an anesthesiologist, he is limiting his study to patients treated for pain after undergoing surgery in four Hamilton hospitals – Hamilton General, McMaster University Medical Centre, the Henderson and St. Joseph’s Healthcare, and others with acutely painful medical conditions.

However, he believes the results may ultimately benefit patients in hospitals across Canada who are suffering from a wide range of painful conditions – from falling out of bed to receiving the wrong medication.

In support of the study, Dr. Paul received $256,000 in funding which includes $120,000 from the national Canadian Patient Safety Institute. Another $136,000 came from Adjuvant Informatics, a Hamilton-based software company which developed an acute pain database for Dr. Paul when he first started looking into this issue five years ago.

In an earlier investigation of 10,033 acute pain patients in three Hamilton hospitals and Toronto General Hospital, Dr. Paul found one out of every 44 patients suffered a "critical incident". This ranged from death (in three patients) to errors in programming pain pumps, respiratory depression (breathing rate slowing down), severe hypotension (drop in blood pressure) and excessive sedation.

For his latest study, Dr. Paul is using a system called Root Cause Analysis (RCA), a tool designed to help identify not only what and how an event occurred, but also why it happened.

"I am going to train all of our acute pain teams on proper root cause analysis using the framework as published by the Canadian Patient Safety Institute," he said.  "It’s going to give us a more systematic and comprehensive approach (to what caused the error)."

Dr. Paul said in medicine it’s common for hospital staff to take the blame personally when things go wrong.  This "self blaming" approach ignores larger system problems that contribute to the problem.   "It’s possible to take a systems approach (as with Root Cause Analysis) and identify where the system let people down." 

For example, errors with patient-controlled pain pumps may happen because the pump wasn’t easy to program, the font was too small, or the educational program for staff was inadequate. "These are the kinds of things Root Cause Analysis can (uncover) because if you just keep blaming people and saying they shouldn’t make an error, then nothing is going to change," he said.

Once system problems are uncovered, the study involves giving senior hospital administrators the adverse event reports with suggestions on how to improve the system.  If administration doesn’t respond to the report then they will receive friendly reminders (from the online tracking system) every two weeks until the safety loop is complete. 

As part of the study, an acute pain newsletter is being developed, as well as a website, which will inform hospital staff and administrators about mistakes that were uncovered, and the root causes which led to them.

"As an acute care teaching hospital, Hamilton Health Sciences (HHS) is strongly committed to patient safety and supportive of Dr. Paul’s research," said Murray Martin, President and CEO of HHS.  "We have made patient safety one of our highest organizational priorities and we now have more than 350 front line staff members acting as patient safety ‘champions’." 

Dr. Paul will be one of the presenters at HHS’ fourth annual patient safety symposium that will take place at the Hamilton Convention Centre on May 31, 2007.

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