Managing Adverse Events in Health Care

Kirstin Borgerson considers responses to adverse events in mainstream and alternative medicine.

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Canadians reading this blog will likely be familiar with the case of Ezekiel Stephan. Ezekiel was a 19-month old child who died of bacterial meningitis in 2012. His parents, David and Collett Stephan, were found criminally responsible for failing to provide the necessities of life. The ruling focused on their reluctance to visit a medical doctor even as the symptoms exhibited by their son escalated dramatically. The basic facts of the case are here.

In response to this case, 43 physicians wrote to a letter to the College of Naturopathic Doctors of Alberta calling for an investigation of the naturopath the parents consulted, and that investigation is now proceeding. The province’s Health Minister has also weighed in on the issue, indicating that she will be reviewing the regulations that govern naturopathy, with an eye to strengthening them. The case also elicited heated responses from parents, health care providers, citizens, and legislators, many of whom have argued that Canada needs stiffer criminal penalties in these sorts of cases.

Photo Credit: Angel Petropanagos

Photo Credit: Angel Petropanagos

In addition to these responses, there have been a range of specific proposals in the domain of health policy, including: eliminating self-regulation for naturopaths and other alternative health care providers; prohibiting the use of certain titles (like doctor) by naturopaths; banning herbal products from pharmacies; and eliminating Health Canada’s role in regulating Natural Health Products.

Underlying each of these proposals is a judgement that the naturopath involved in this case did something wrong. Perhaps the naturopath failed to adequately emphasize the vital importance of seeking emergency medical care. Or, perhaps there was a more serious error that involved dispensing a treatment without seeing the patient in question. In other words, the death of this child is considered an “adverse event.”

Adverse events arise from health care management and involve unintended injuries or complications that result in death, disability, or a prolonged hospital stay. Even if we limit our concern to adverse events occurring in hospitals, they are the third leading cause of death in the United States, according to an article recently released in the BMJ and reported by the CBC. They are also a concern in Canada. One landmark Canadian report of patient safety in hospitals found that there were approximately 70,000 preventable adverse events during the year studied of which as many as 23,750 were preventable deaths.

A range of strategies have been introduced to decrease the rate of adverse events in the mainstream health care system. Key to these efforts is a rejection of the culture of “shaming and blaming” within medicine, because it impedes efforts to identify system failures and learn from mistakes. Experts emphasize the importance of clear reporting mechanisms, monitoring by regulatory bodies, and better communication and coordination among caregivers.

Ezekiel’s death has much in common with the adverse events documented in hospitals: the death of a patient, the involvement of health care providers, and a judgement that the death might have been prevented. However, a clear difference between this adverse event and those that occurs in hospitals is that the health care provider of interest in Ezekiel’s case was outside of the mainstream medical system.

There are other notable differences, such as the wide-ranging scope and severity of the solutions offered in Ezekiel’s case. None of the responses listed above align with the solutions proposed for managing adverse events in mainstream medicine. In fact, the proposals in Ezekiel’s case are either precisely what has been shown to fail in reducing adverse events in hospitals (blaming and shaming individuals), or are so severe that they can’t even be articulated in the medical case (for instance, eliminating professional self-regulation or banning whole classes of medical treatments).

Why are the responses to these cases so different? If we want to be consistent, we either need to find a meaningful difference or we need to adjust our responses.

If we are aiming for consistency, we could hold alternative health professions to the mainstream standards developed for preventing adverse events. For example, we would try to improve the reporting mechanisms within the naturopathic profession. We would certainly maintain rather than abandon Health Canada’s oversight of the profession and regulation of alternative health products. And we would turn our attention to improving communication and coordination of care – for instance, between naturopaths and emergency room staff or family physicians.

However, as I remind my students, it is always worth considering alternative routes to consistency. In this case, one possibility would be to increase the severity and scope of responses to adverse events in mainstream medicine. This approach may not be as outlandish as it sounds, given that rates of adverse events seem to be increasing in spite of extensive efforts to bring them down. Perhaps the real lesson to be learned from this case is that efforts to reduce preventable deaths need more force, in all domains.

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Kirstin Borgerson is an Associate Professor in the Department of Philosophy, Dalhousie University. @kborgerson