Safety is a shared responsibility: a 10-year review of surgical safety incidents in Canada

OTTAWA, April 13, 2016 /CNW/ - The effectiveness and safety of surgery has steadily improved over the last many decades in Canada. There are now over one million surgical procedures performed annually. Nevertheless, despite the significant improvements in patient outcomes, patient safety incidents do sometimes occur.  

A detailed review of medico-legal cases in Canada between 2004 and 2013 reveals that a large number are related to surgical care.

This review was conducted by The Canadian Medical Protective Association (CMPA) and the Healthcare Insurance Reciprocal of Canada (HIROC) who combined their surgical safety incident data collected over that 10-year span to produce a retrospective analysis. The two organizations, along with the Canadian Patient Safety Institute, are using the findings to advocate for extensive system and practice improvements.

In their analysis, the organizations identified 1,583 CMPA and 1,391 HIROC medico-legal cases involving an in-hospital surgical incident. Retained foreign bodies or wrong surgery were identified in 12 per cent of CMPA and 18 per cent of HIROC surgical safety incidents.

System factors – a lack of or non-adherence to a surgical safety protocol – were also found to be key contributors to surgical safety incidents.

"This review clearly shows that we need to maintain our focus and continue to build capacity in surgical safety," said Polly Stevens, VP, Healthcare Risk Management at HIROC.

The analysis is the result of a request made of the CMPA and HIROC by members of the National Integrated Patient Safety Consortium, an initiative facilitated by the Canadian Patient Safety Institute. The group of more than 50 healthcare organizations is united in their pursuit of safer care for all Canadians.

"Working together on this review provided the opportunity for shared learning about surgical safety," continued Stevens. "We really benefitted from each other's unique databases and areas of knowledge."

The results of their review have renewed the partners' commitment to pushing even harder for systemic and workplace cultural changes within the healthcare environment.

"As we go forward, this is about building better healthcare systems and encouraging team training so that surgical outcomes are further improved," said Dr. Hartley Stern, CEO of the CMPA.

"Surgical safety is a key element of patient safety," said Stern. "This report contains valuable lessons and recommendations that surgical care providers can use to provide the best care possible. The CMPA, through its commitment to contributing to safe care and the prevention of harm to patients, is proud to be involved in this work."

"Improving surgical safety culture requires the cooperation and commitment of the entire healthcare team in the adoption of safe practices," said Chris Power, CEO of the Canadian Patient Safety Institute.  "In keeping with the mandate of the Patient Safety Institute we will take these recommendations and work with patients, leaders and providers to achieve a culture of surgical safety with improved patient outcomes."

A Summary Report and full copy of the Detailed Analysis can be found at:, and

About the Canadian Medical Protective Association (CMPA)
The Canadian Medical Protective Association (CMPA) is a not-for-profit organization that has delivered medical liability protection in a cost-effective and ethical manner since 1901. CMPA medical-legal protection enables physicians to practise confidently and to make decisions that result in better patient care and a more efficient healthcare system. The CMPA's mission is to protect the professional integrity of physicians and promote safe medical care in Canada. Our vision is to be valued as an essential component of the Canadian healthcare system.

HIROC (Healthcare Insurance Reciprocal of Canada) is Canada's leading provider of healthcare liability insurance. HIROC works in partnership with its 600 subscriber organizations to develop cost-effective insurance & risk management solutions that prevent losses, mitigate risk and support safety in healthcare. As a not-for-profit reciprocal, HIROC is owned by its subscribers and is dedicated to giving back – since inception, HIROC has given $120 million back to healthcare.

About the Canadian Patient Safety Institute (CPSI)
The Canadian Patient Safety Institute (CPSI) is a not-for-profit organization that exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety.  Funded by Health Canada, CPSI reflects the desire to close the gap between the healthcare we have and the healthcare we deserve.

SOURCE Canadian Patient Safety Institute

For further information: For media inquiries, please contact: Cecilia Bloxom, Director of Strategic Communications, Canadian Patient Safety Institute, 780-700-8642,; Ellen Gardner, Manager, Communications and Marketing, HIROC, 416-730-3085,; Isabelle des Chênes, Director of Communications, Canadian Medical Protective Association, 613-725-9965 ext. 344,


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