Insights November 2008

Scary Headlines We Don't See

Steven Lewis

Recycling isn't always a good thing. News of syringe reuse in Alberta and Saskatchewan health regions provoked the predictable avalanche of concern, outrage, fear and puzzlement. How could it happen? Who's at risk? What's the root cause: penny-pinching? incompetence? negligence? Naturally, the media are all over it - at least several hundred stories and tens of thousands of Google-generated web results. Thousands of patients fear they may be the unlucky victims of the latest endoscopy and anesthetic misadventures.

Ya gotta wonder. Some things in healthcare are complicated, but some are simple. Wash your hands. Give the heart attack patient an aspirin. Chuck the syringe. How is it that the system does dramatically complex stuff well and screws up simple stuff routinely? Good people quit thinking - happens to me, happens to nurses. It's the night watchman's challenge: how do you stay sharp for the ten thousandth iteration of a common and low-risk task? It's not impossible: Six Sigma for aviation; Sick Sigma for healthcare.

There's a lot to be pissed about in healthcare - just read Baker and Norton on safety, McGlynn and Katz on the staggering failures of primary care, Sinclair on the Winnipeg baby deaths, pathological pathology in Ontario … The media spotlight shines on the farces and cover-ups, retails heart-tugging victims' tales and psycho-biographies of perpetrators felled by bad judgment, hubris or both. Scandal! Hearts of Darkness!

Meanwhile, the quality improvement and patient safety mavens ruefully observe yet another absurdity and gamely stick to the script du decade: people are good, systems are faulty; put away the lash and enrol people in collaboratives; re-engineer, don't recriminate. Politicians and administrators face a parallel reality: how does chalking it up to "system error" satisfy the deeply ingrained yearning to make the bastards pay? Quality Improvement, meet the Vengeance Posse. Enjoy your conversation.

So, how should the media report on the syringe reuse debacle? The problem is not so much what the media have said about it - the reporting has been reasonably balanced, noting the very low risk of serious harm and pressing (unsuccessfully) for statements from experts on the odds of being unlucky. The unmet challenge is to interpret the issue in context. How risky is syringe reuse compared with filling your prescription or walking into an emergency room? Should people be more worried about high-profile misdeeds or the risks inherent in substandard everyday care?

Here are some candidates for full monty media coverage - practices that without question harm more people than reused syringes, inconvenience the public and patients, drive up costs or create gaps in the system.

Health Region Knows Handwritten Prescriptions Put Patients at Risk but Allows the Practice Anyway

Despite overwhelming evidence that handwritten prescriptions harm and even kill patients, the local health region has not taken steps to halt this practice in its facilities. Nor has the province required system-wide electronic prescribing and the use of software to alert doctors and pharmacists to contraindicated drug combinations. The thousands of seniors on six or more medications should be extremely worried since they have a 94% chance of suffering an adverse drug reaction.

Doctors Don't Have to Adopt Electronic Health Records If They Don't Feel Like It

Electronic health records are used by fewer physicians in Canada than in any other G7 country, and that seems to be fine with the governments who pay them on our behalf. Many patients have complex conditions treated by several providers, and everyone faces the risk of getting sick away from home and visiting an emergency room in another town. There's almost no chance that their complete health record will be available instantly to the specialist or the emergency team. Customers of banks without ATMs and who enter deposits and withdrawals manually in passbooks and wide ledgers will be familiar with Canadian healthcare practices.

Many Patients Not Allowed to Tell Doctor What's Ailing Them in Single Visit

Patients who inconveniently have several symptoms and health complaints should not bother their doctors with more than one per visit. Many physicians impose the one-complaint-per-visit rule on their patients. Even though some regulatory bodies frown on the practice, it remains widespread. The policy is in response to a fee schedule that discourages doctors from spending time with patients who have complex health issues.

Higher Credentials Result in Less Training for Some Healthcare Workers

Think that newly minted graduate with a master's degree in physiotherapy (PT) has more training than the baccalaureate graduate of old? Think again. PT is just one of several professions that have ramped up their entry-to-practice credential requirements. But it's not a master's degree on top of an undergraduate PT degree; it's on top of any degree. The result? Now it takes six years to turn out a physiotherapist with two years of discipline-specific training, instead of four years to produce one with four years of discipline-specific training.

Of course, the media should jump on the syringe reuse story - it is newsworthy, it should not happen, it is a (small) threat to public safety. But it's also important to tally up the harms throughout the system. In Canadian healthcare, more people die every day from avoidable error than the combined toll from the most high-profile and egregious misdeeds. Canadians should worry more about the general standard of practice than about the prospect of falling victim to brazen or malicious incompetence. And the media could provide a great service by shedding bright and constant light on these routine, persistent and costly failures.

To respond, please comment on the blog.

Steven Lewis is a Saskatoon-based health policy consultant and part-time academic who thinks the health care system needs to get a lot better a lot faster.


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