As a senior healthcare executive, I experienced several incidents in which patients were adversely affected, though no one had intended to harm or compromise anyone. While these were all difficult and painful, I remember one in particular, in which a patient died on a procedure table due to medication overdose. I remember the emotions of the parents and everyone involved as if it were yesterday. All knew this was an unnecessary loss. Anyone who has worked in a hospital any length of time has seen patients grievously affected by an adverse event. No one goes to work in healthcare anywhere wanting to make an error. Canada's health professionals and our many other staff are committed to providing care to anyone in need. But occasionally something does go wrong. We know that somewhere between 9,000 and 24,000 people die annually (Baker et al. 2004) from an adverse event in hospitals. And how many more have been adversely affected in home care, long-term care or community care? The research mostly has yet to be done in those areas.

So who is responsible? And who is going to "fix" the now-well-known problem documented by Baker et al.? We are not going to fix the problems by focusing on individual(s) caregivers; instead we need to focus on the system. I have travelled across the country and heard from professional caregivers - doctors, nurses, pharmacists and many others - and they yearn to give safer care. That aim resonates with Canadian CEOs who recently attended a session with Dr. Donald Berwick, CEO of the U.S. Institute for Healthcare Improvement.

To get at the issue, boards and CEOs of hospitals must make patient safety a priority, and a few have begun this journey. So too must community and other healthcare organizations. Researchers must help us better understand the problems and the underlying causes - be they processes, human factors, design of equipment or supplies, systems, etc. We must learn from the work of the airline industry and other high-risk ventures that make safety a priority. We must learn and apply all of this to our complex system of healthcare. It will not be easy and it will take time.

I believe that part of what has created compromises in patient safety is the fact that we are asking our staff to master new technologies, processes, drugs, equipment, knowledge, etc. at an alarming rate, and asking them to be increasingly efficient and effective.

The culture of our organizations must change. Being able to report adverse events without blame or retribution, to participate in addressing the causes and to disseminate the lessons learned is part of the solution. This includes permitting patients a voice and some responsibility in their care. It is up to all of us, and leaders such as the boards and the CEOs, to be passionately committed to a different culture. The patients deserve nothing less.

Suppliers of medical products must also make this a priority. Issues have been identified, which they can remedy, in the design, labelling and other features of healthcare equipment, medical supplies and medications. They too must be part of the intricate solutions.

This special issue of Healthcare Quarterly is a piece of the puzzle, sharing knowledge and providing hope for each of us that there are solutions. We trust it will help us all become better at caring for our patients and for each other. We have had overwhelming response to this first edition. We thank the authors who have contributed to this publication. We also thank the many who submitted whom we were not able to publish at this time due to space limitations (after expanding to well over 150 pages!). Clearly there will be more to come in the future.

Most importantly, this is dedicated to our patients.

About the Author

Phil Hassan, President and CEO

References

Baker G.R., P.G. Norton, V. Flintoft, R. Blais, A. Brown, J. Cox, E. Etchells, W.A. Ghali, P. Hebert, S.R. Majumdar, M. O'Beirne, L. Palacios-Derflingher, R.J. Reid, S. Sheps and R. Tamblyn. 2005. "The Canadian Adverse Events Study: The Incidence of Adverse Events among Hospital Patients in Canada." Canadian Medical Association Journal 170(11): 1678-86.