Avoidable Harm?

CIHI releases HSMR trends for Canadian hospitals

Hospital standardized mortality ratio allows hospitals to track quality of care improvements over time

Another Canadian view!?

We are improving though?

First developed in the United Kingdom and used in several countries throughout the world,
the HSMR was adapted for use in Canada by CIHI.

Here's some UK news.

NHS warned to cut errors in hospitals and surgeries

Mistakes are made, but NHS is getting better

Brain Death Diagnosis

"Haleigh Poutre speaks

Her case revealed massive,
dangerous bureaucratic incompetence
and the fallibility of the medical establishment."?

The miracle of Haleigh Poutre

Editorial:
Haleigh Poutre, ‘Persistent Vegetative States’ and Compassion

Stepfather to serve 12 to 15 years in Haleigh Poutre case
December 18, 2008

December 30, 2008

Best Medical/Health Issues Blog

BOO HOO

No Award This Year

Chief medical officer condemns organ donor decision

"The government's chief medical officer last night lashed out at the decision to ditch planned reforms for organ donations, warning that dying patients had been left on a 'knife-edge of despair'."

The benefits of 'opting out' are overstated

Is "TRUST" or the lack of trust in the current policy system of "self regulation" significant?

Perception

Shipman?

Powell?
and
Truth?

Alder Hey?

Legally dead?
Actually dead?
Medically dead?

The Goudge Inquiry?

Commission of Inquiry on Hormone Receptor Testing?

Miramichi Regional Health?

Hospital to bury unclaimed organs

Hannah's choice

"Hannah Jones has refused the heart transplant that could save her life.
But is a 13-year-old too young to make that decision?

Or is she the only person who can?"

"........., a former nurse who had worked in intensive care, and Hannah's father, Andrew, an auditor, are furious that the doctors appeared to assume that not only were they not acting in their daughter's best interests, but that Hannah was incapable of making a life-or-death decision."

'We told her we loved her.
She said, "Thank you for everything"'

Hannah's Choice: Saying No to a New Heart


Transplant for heart refusal girl
29 July 2009

Emergency-room nightmares

Emergency-room nightmares spur calls for action

A homeless man and double amputee,
died after sitting 34 hours in a Winnipeg emergency room

Reusing Syringes

A hospital in Lloydminster, Sask., has been reusing syringes to inject medication into intravenous lines, a practice that recently raised widespread concern in Alberta.

A common practice?

Syringe reuse for IV lines not just in High Prairie: nurses union


Respect for patients?

Previous post

At one time surgery staff washed up after
all the surgeries were completed.
Why wash up before? Surgery is a messy, dirty business!

A guide to the Hippocratic Oath

When I asked my medical students to name famous doctors in the history of medicine, their first answer was Harold Shipman, the GP who murdered hundreds of patients.

Man dead 'for some time' in Winnipeg ER before staff alerted

Judge recommends more legal funding
for family of Brian Sinclair in inquest

Is this a clear demonstration on the effectiveness of the Winnipeg Regional Health Authority's (WRHA) review of its approach to patients harmed as a result of breakdowns in the provision of care provided to the population it serves?

Medical errors killing
 up to 24,000 
Canadians a year

That's more than 2 every hour!

Nearly a Quarter of Canadians Report
a Preventable Adverse Event
in Own Care or That of a Family Member
Click here

Man's death in Winnipeg ER 'preventable'
chief medical examiner

A man waited 34 hours in the
Winnipeg Health Sciences Centre emergency room,
but died without getting treatment.

Ottawa's ER's are more compassionate?

'A disgrace'So WE WAITED AROUND 17 HOURS to see a doctor for 7 minutes

Do no harm

Discussions after Harm in the Healthcare Setting

“ If you take my pen and say you are sorry
and don’t give me back my pen,
nothing has happened.”
– attributed to Bishop Desmond Tutu.


OOPS, Sorry!

How Hospitals are Killing ER Patients

Quick harvest of infant hearts incites debate

"Cases raise touchy ethical question: When to declare organ donors dead?"

ETHICAL?

Earlier harvesting of hearts

stirs ethics debate

ETHICAL?

Doctors facing 'five-year MOTs (relicensing)'

"The government committed itself to introducing a system of relicensing the UK's 150,000 doctors last year to test their basic competence as a medic."

They have a year and a half to get it right!

"Written laws are like spider's webs;
they will catch, it is true, the weak and the poor,
but would be torn in pieces by the rich and powerful."
(Anacharsis--Scythian Philosopher...600 B.C.)

Ontario called on to improve nursing home conditions

"Disgraceful conditions in the province's nursing homes"

Vast majority of Toronto's nursing homes cited
for failing provincial standards

Much more than mere incidents

Doctor Charles Smith Seen As Part Of A
Larger Pathology And Medicare Crisis In Canada
In Globe And Mail History:
"Much More Than Mere Incidents"

Access to Information

Stop The Press:
Part Two; Access to Information Request:

A very informative Blog post!

Emergency room visit strips man, 81, of dignity

Patient went AWOL under nurses' noses

Is this "Standard of Care" acceptable?
Corrective action will be taken!?
Definitively!

Pathology errors spark concern over hospital laboratories

Is this a crisis!?‽

Maybe the accepted "Standard of Practice" that has evolved from "Self Regulation" is a contributing factor to the crisis‽

SELF REGULATING? - SELF SERVING?

Samson and Goliath,
Who will be the winner?

Brain death diagnosis

An organ harvest was begun, that was until he moved his arm.

Four months after he was declared brain dead
and doctors were about to remove his organs for transplant,
Zach Dunlap says he feels "pretty good."

Man Makes “Miraculous” Recovery from Brain Death

When brain death isn't terminal
The case of a revived 'brain-dead' accident victim raises some disturbing issues
Apr 13, 2008


Brain Death is the irreversible cessation of all brain function including that of the brain stem.
There is no possibility of recovery in this situation and once brain death has been confirmed,
the patient is legally dead.
Reassuring?

Legally dead?
Actually dead?
Medically dead?
Maybe dead?

Haleigh Poutre speaks


DECLARED BRAIN DEAD
PARENTS REFUSED TO EUTHANIZE
WOKE UP FROM COMA

the charles smith blog

"An Extraordinary Development in Canada:
Three Inquiries Based on Flawed Pathology In One Country At The Same Time;
Crisis?"

Not really an extraordinary development.
Pathology standards, as well as all other medical standards,
appear to have been consistent for years.
Is this another example?

Father credited for acquittal in baby's death
April 4, 2008

Saturday, April 5, 2008

CPSI launches first-ever Canadian Disclosure Guidelines

Guidelines aim to cut medical errors

Another view?

Not right to remain silent about errors, medical guidelines say

This would be an extraordinary, dramatic change from the apparent current practice of cover up with detailed all encompassing meaningless explanations. One can expect the word "appropriate" to be used liberally in a "double entendre" fashion, in an attempt to confound the gullible. Here's an example!?

MD 'secrets' will go public

Malpractice judgments will be posted on College's website, thanks to Star probe

Ethics Honesty
As understood by the public!?
As understood by the
Health Professions Colleges!?
Self Regulation!!!!!!!

W-FIVE Investigates the Secretive World of Medicine and the Toronto Doctor Dozens of Women Claim Injured Them

W-FIVE: Right to Know
Streaming video of the program on this link
Updated Fri. Feb. 29 2008 11:13 AM ET
:¬ (

Patient fired by her doctor

Equal Justice For All?

Premier's fan accused of death threats

And is the following an example of consistency in the application of justice?

If an organization repeatedly reiterates what they know will be interpreted as a threat, then is it not logical to assume that they have knowingly given the threat? Isn't a threat to cause harm or death a criminal offence in most of Canada?

Maybe the perceived difference is due to the fact that the second example deals with the exemplary ethical, self regulating, law respecting honest medical profession?

Probably so!

The Current Inquiry into Pediatric Forensic Pathology in Ontario is clearly an investigation, of a possible aberration, of the profession's ethics?
Maybe the "Shipman Inquiry", in another jurisdiction, is another example?

Doctors 'must own up to blunders'

"A new culture of honesty and openness should see such patients receive a personal apology from the doctor concerned and a detailed explanation of what went wrong"

One wonders when signs of this "NEW CULTURE" will become evident!

A new culture‽


A continuing culture‽