New CIHI analysis shows varying rates of adverse events in Canada



    OTTAWA, Aug. 14 /CNW Telbec/ - A new analysis on adverse events released
today by the Canadian Institute for Health Information (CIHI) examines the
risk of birth trauma in hospital and a range of other adverse events,
including medication errors, in-hospital hip fractures and problems related to
blood transfusions. Focusing on results from recent surveys, as well as
several patient safety indicators, Patient Safety in Canada, shows that some
adverse events are comparatively rare, but others occur more frequently. For
example, in 2005, 1 in 10 adults with health problems reported receiving the
wrong medication or wrong dose in the previous year. Adverse blood transfusion
events are reported much less often. They occurred in about 1 in 4,100 cases
in 2003.
    "While we do not know how to prevent all adverse events, tracking how
often they occur and understanding the factors that contribute to them is an
important step in improving patient safety," says Dr. Jennifer Zelmer, CIHI's
Vice-President of Research and Analysis.

    One in 141 babies experience birth trauma each year; one in 21 women
    experience obstetric trauma

    There are over one quarter of a million babies born in Canadian hospitals
each year (outside of Quebec), one of the leading reasons for hospitalization
in Canada. While most deliveries proceed smoothly, adverse events do occur in
some cases. For example, the analysis found that between April 2003 and March
2006, on average, one in 141 babies born in hospitals outside of Quebec
experienced birth trauma, such as injuries to a baby's scalp and nervous
system or skull fractures. This represents more than 1,700 cases yearly.
    Likewise, 1 out of 21 mothers giving birth by vaginal delivery (almost
5%) experience obstetrical traumas, such as lacerations of the cervix, vaginal
wall or sulcus, or injury to the bladder or urethra. Between April 2003 and
March 2006, there were, on average, more than 9,100 reported obstetric traumas
in Canadian hospitals outside of Quebec each year. Previous research suggests
that risk factors for obstetric trauma include newborns weighing more than   
4 kg, long labour, instrumental delivery and a woman's position during birth.

    Risk of post-admission pulmonary embolisms measured for the first time

    CIHI's analysis found that 3.6 out of every 1,000 patients in Canadian
hospitals (outside of Quebec and parts of Manitoba) experience a pulmonary
embolism (PE), which occurs when a blood clot or globule of fat or tissue
travels through the veins and into the lung. It usually originates in a vein
in the leg, when it is known as deep vein thrombosis (DVT).
    The risk of post-admission PE or DVT generally increases with age, with
patients 60 and over at higher risk than younger patients. However, the rate
among children 4 and under is statistically significantly higher compared to
that for older children up to 17 years of age.

    Reducing the risk of foreign objects left in after surgery

    Foreign objects left in after a procedure are less common than many other
adverse events, affecting about 1 in 3,000 inpatients in Canadian hospitals
outside of Quebec and parts of Manitoba, resulting in more than 200 cases per
year between 2003-2004 and 2005-2006.
    Previous studies show that obese patients are at higher risk of having a
foreign object left behind after surgery. Other higher risk groups include
patients who undergo emergency operations, have an unexpected change in
operation or have a change in nursing or surgical staff during a procedure.
Patients aged 17 and under are at lower risk than adults.
    "The consequences of leaving a sponge or other foreign object in after
surgery can be significant, but experts suggest that targeted strategies can
reduce the risk," says Dr. Indra Pulcins, CIHI's Director of Health Reports
and Analysis. "Documented prevention strategies include following a strict
practice of sponge and instrument counts, as well as vigilant inspection of
body cavities when the surgery is complete."

    Improving patient safety

    "Health professionals always give their best efforts yet the fact remains
that problems or adverse events happen during care delivery," said Phil
Hassen, CEO of the Canadian Patient Safety Institute. "By being vigilant in
our focus on patient safety, we hope to see changes in practice that will
significantly reduce needless injuries and deaths that result from adverse
events."
    For example, many health care providers are focused on reducing the risk
of medication errors. In a survey conducted in 2006, 8% of primary care
doctors reported that patients had received the wrong drug or dose in the last
12 months. In 2005, 18% of nurses surveyed reported that patients in their
care had occasionally or frequently received the wrong medication or dose in
the previous year.
    Experts have suggested a number of strategies to reduce the risk,
including medication reconciliation - the process designed to prevent
medication errors at patient transition points - (recently made an
accreditation requirement for Canadian health care facilities) and automated
drug alerts. In 2006, 10% of Canadian primary care physicians reported
routinely receiving computerized alerts about potential drug interactions or
dose problems. (Another 31% said that they received this information using a
manual system.) Canada's 10% compares with 23% in the United States, 40% in
Germany and 80% or more in Australia, New Zealand, the Netherlands and the
United Kingdom.

    About CIHI

    The Canadian Institute for Health Information (CIHI) collects and
analyzes information on health and health care in Canada and makes it publicly
available. Canada's federal, provincial and territorial governments created
CIHI as a not-for-profit, independent organization dedicated to forging a
common approach to Canadian health information. CIHI's goal: to provide
timely, accurate and comparable information. CIHI's data and reports inform
health policies, support the effective delivery of health services and raise
awareness among Canadians of the factors that contribute to good health.

    
    This media release is also available from CIHI's website at www.cihi.ca.

    Table 1.   (Table 2 in analysis) - Average Number Exposed per Patient
               Safety Event in Canada

    Figure 1.  (Figure 3 in analysis) - Rate of Obstetrical Trauma During
               Vaginal Delivery, by Age Group

    Figure 2.  (Figure 4 in analysis) - Rate of Foreign Objects Left in After
               Procedure, by Age Group

    Figure 3.  (Figure 5 in analysis) - Rate of Post-Admission Pulmonary
               Embolism or Deep Vein Thrombosis, by Age Group

    Figure 4.  (Figure 7 in analysis) - Doctor Routinely Receives Alert About
               Potential Problem  With Drug Dose/Interaction
    




For further information:

For further information: Media contacts: Christina Lawand, (613)
241-7860 ext. 4310, Cell: (613) 299-5695, clawand@cihi.ca; Leona
Hollingsworth, (613) 241-7860 ext. 4140, Cell: (613) 612-3914,
lhollingsworth@cihi.ca


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