Winnipeg Free Press

Winnipeg Free Press (Newspaper) - December 7, 2000, Winnipeg, Manitoba Focus a17 Vav Inmei Fhi i tin Dic Mirim 2000 what you should know about your surgeon Catherine Mitchell looks at a recommendation from the baby death inquest deaths in Hospital within 30 Days of surgery All Ndel salons rates per 100 Coo 200 600 the do represents me the England of the line represents Isle of i Rill we Impi Confidence Awn in the data Brent Harrosh Wiltshire in Meh Sou Wirk and Dorset Somerset Oxfordshire arse South Wesl Harp some North and Easl do void Herefordshire Cor Vaif and Isles of Scilly West Sussex Selton Wesl Hertfordshire North Cheshire eur Sussex Brit him Tovo North Yorkshire Sunderland Leeds Serroy Darnel Portsmouth and Soulli Easl Hampshire East Kent Rel Tiringo and Wall two f test tees North Cumbria Jasund Monti Hertfordshire and Wesl Devon last week Manitoban were told by the head of the health sciences Centre not to hold their collective breath waiting for concise and objective data on a surgeons track record in the operating John Home said such report cards Are a Long Way because no one keeps track of that track records called surgical out come analysis for hospitals and surgeons have been compiled in other Home is though it Hast been done in but it can be done in a project to do this was pro posed right Here in in the Manitoba Centre for health policy and evaluation worked with the College of physicians and surgeons to measure the effective Ness of the centres research helped draw up clinical guide lines following the death of a youth in Rural Manitoba during a their finding that Tonsillectomy rates were higher in Rural Manitoba than in Winnipeg led to a Call for doctors to reduce the number of such As a Pilot it was a the Centre then offered to collect and Analyse data on a variety of surgical pro but the College said col lege officials noted their mandate is to regulate and police the medical proves not to Monitor or improve the qual Ity of performance evaluations so much for one of the most helpful recommendations judge Murray sin Clair handed and canadians in out of his review of the Messy work of Jonah judge Sinclair concluded patients should have reliable performance evaluations before they consent to a surgeon of distinguished Edu cation but second rate was recruited to Hsc in 1994 to satisfy an institutions ambition to offer More and More prestigious surgical though that would stress their dims and the abdication of anything resembling leadership at led to the deaths of 12 babies and shattering their families and rocking the lives and careers of a Bunch of dedicated or nurses and some this betrayal was caused not by one but by a desperately flawed system for catching there is no reason that Canadian health Consumers must rely on Little More than their surgeons word instead of hard evidence by which to measure both Britain and a couple of the states publish the surgical outcome results directly for the notes Charlyn a co director of the Manitoba Centre for health policy and Eval its not just the professional organizations that review what in worried about is in Canada its used neither for professional nor for Public while data can be used to improve the Odim was described As one of the and the Hsc comparable to any in these platitudes can be heard in the Halls of any health Centre any Day of the j judge in his exhaustive and methodical report on the inquest into the 12 said the Lack of information on a doctors or a hospitals performance undermines what is commonly referred to As informed the process whereby the physician reviews the risks and benefits of a procedure with a when fully the patient should have the ability to decide whether the operation is right for judge Sinclair concluded that publishing a patients handbook on what questions to ask the physician and the Hospital would allow patients to measure the trouble some doctors dont believe their own track records Are Ger mane to the Issue of medical staff told the inquest that declaring ones medical experience is not a requirement for informed patients families were not sometimes even after How Many times the surgeon had done a particular the Success rate or How the hospitals program com pared to those beyond being denied they were Given wrong and when they asked for they were in Addi All the checks and balances built into the system were meaning less in a place that cared not to know who was responsible for the health sciences like All Winnipeg is a self policing entity under the hospitals there were eight review most of them that could have stopped the carnage had they just done their senior med ical staff also failed in their ignoring the complaints of nurses and anaesthetists while allowing doctors with vested interests in the cardiac program to sit on the bodies reviewing mistakes made in the or Odim himself sat on one of the review the College of physicians and surgeons is not without blame it has responsibility to ensure doctors licensed in Manitoba have the required unchecked the result was that families were led into surgeries too difficult for a surgeon unqualified but All the while nurses and doctors inside Hsc were secretly telling family and friends to steer Clear of the heart surgery pro Black says part of the problem with the current system of self policing is that it focuses on blame and fault to Correct this adversarial system is not conducive to a full airing of what leads to the system needs not the people Are always going to make other countries have started such research and data collection on medical errors and performance Are being used to empower provide informed consent and improve the Quality of in the United prime minis Ter Tony Blair launched a Campaign to England i Broncy Wesl Hertfordshire Worcestershire i Buckinghamshire Sii Lolk a Tomilon Southampton Anil so Hin Toshire current culture of Medicine reinforces the belief that medical personnel must perform without All too the making of an error in Medicine is equated with a moral failing or is regarded As a sign of ignorance or to admit to or to imply that a colleagues actions were in is to raise serious questions about someones and hence legitimacy and authority within the healthcare judge Murray inquiry into the twelve deaths at the Winnipeg health sciences Centre in improve Public health the National health ser vice now compiles data on surgical out comes and waiting lists of various hospitals and publishes easy thread graphs in the in the United n a 1999 study of medical errors has shown that mis takes in hospitals cause at least and perhaps As Many As deaths per year even by the lowest medical errors cause More deaths annually than car breast cancer or medication in or out of accounts for an estimated some hospitals Are also measuring surgical outcomes for mistakes in Hospi tals Are referred to As judge sin Clair found that errors Are common but rarely Lead to comply and therefore Are rarely when there record they Are dismissed unless there is a Nega Tive this is no Way to learn from he it should be noted that patients Are not privy to incident reports although mis takes can be recorded on medical Black says the result of the american study called to err is human published a year ago by the Institute of Medicine in Trig gered an increase of funding for research into medical a former general Black believes this research and data analysis along with the Public pressure they put on politicians and health care providers is the Best Way to Reform our our system has too Long relied on peer review and monitoring to some civil to catch and Correct mistakes that some times costs deaths from heart attack i number of deaths in per within 30 Days of emergency admission with a heart 199899 i i i i cancer five year relative of women aged 1599 diagnosed with breast cancer during the periods 19911993 the Dol represents the so 65 70 75 80b5 90 indicator Ihrl Waslh England per Fertaw life Ian it uie line represents East Surrey the level of Confidence milling done i in the Date i Bromley Kingston and Richmond Wal Hertfordshire Camilon and Islington still Lull Barnsley ii yield and Hai Ingay Sloo port Shropshire West Sussex Southampton and South Wesl Hampshire Redbir Jorje Malihom Fores Warwickshire East a Matilon it Hove Soult Worcestershire Easl London Axll Lucily so title Lancashire Virjan ii Rel Bollon East Surrey East rklir3 Bradford a Fol Lancashire stat Isle and Nolti to Node Sams Lcy Fralli deities Liviu Rol Huriam sail re trial Lrol reports from British hospitals published in newspapers 111 there is a Public perception that Doc tors conjure the Power of holding Sway Over the lives of the sick who come seeking Jonah Odim knew before Odim set eyes on fou year old Vinay cardiologist Niels Gid Dens assured the toddlers parents recruited to the health sciences Centre from Boston no was one of the Odim assured them he had intimate experience with the Type of operation Vinay he in never undertaken such a procedure on his the goals told Odim that he was like god to Vineys death was one of four judge sin Clair ruled was none of the families of the 12 children was provided with sufficient information to allow them to give informed consent to the misled by Faith blinded by desperation the goals and All of the fam Ilies simply believed what they were what they were told was not the whole doonesbury patient handbook recommended judge Murray Sinclair conducted the inquest into the 12 deaths of children in 1994 under the health sciences centres Pedi Atric heart surgery pro among his conclusions was that patients or their families Are not told what they need to know to give informed consent for he has recommended the health department publish a setting out their including i the right to be fully informed before giving con sent to medical treatment i the right to information about a surgeons experience in performing a partic ular As Well As the experience of the Hospi Tal surgical team i the right to a second opinion i the right to an out of province referral in certain including where the patient or Parent chooses to have a proce Dure performed by a sur Geon or institution with More appropriate experience and where the surgeon or institution in Manitoba lacks the same experience i the right to have an out of province surgeon per form the procedure in provided that there is a surgeon willing and Able to do the proce Dure judge Sinclair also recommended the health department Tell Manitoba hospitals in order to obtain informed they have an obligation to provide this to patients or their oui want but in w a 0a0y ;