David U was first struck by the tragic ripple effect of medication errors back in 2003.
The president and CEO of the Institute for Safe Medication Practices Canada (ISMP - Canada) had been called as an expert witness for a coroner's inquest into the death of a hospital patient. The death occurred after a nurse mistakenly flushed the patient's intravenous line with concentrated potassium chloride — a chemical used in lethal injections — rather than the intended normal saline. At the time the two solutions were stored and dispensed in almost identical vials in healthcare facilities across the country.
A pharmacist with more than 40 years experience, U remembers staying up late one evening at his Ontario home to prepare for his testimony the following day. As he pored over the case reviews and investigative reports filed in the aftermath of the death, including the account of one deeply traumatized nurse, he was deeply moved.
"I remember all the boxes of stuff in my little study in my house," U says. "Everyone, my kids and my wife, were already asleep and it was just so sad, the fact that all these things happened. I could see that this was not the nurse's performance issue, or any mistake on her own. I just couldn't help the tears coming to my eyes when I looked at all those documents.
"It told me I had to do something about it. I did do something about it and hopefully this will never happen again, and so far so good."
When U founded ISMP Canada back in 2000, the culture surrounding healthcare-associated harm in Canadian hospitals was still very much one of finger-pointing and blame. Most experienced nurses, physicians and other clinicians have been associated, in some way, with such adverse events but yet at that moment the incident occurs the health provider closest to it can often feel quite alone.
U cites the case of another fatal healthcare mishap that involved the correct medication but the wrong administration. A young cancer patient needing chemotherapy was hooked up to a mobile infusion pump that should have been set to administer the highly toxic drug over four days. Instead the chemo drug was infused over four hours and as a result the woman died almost immediately.
In that case the nurse involved did meet with the patient's family afterwards in an attempt for all parties to grieve and heal together, U recalls.
"In both those cases I didn't see that the family held a big grudge against the provider, which is a good thing. I think we all know they are actually the second victim. I think in both cases the nurses left their profession, and that's also very, very traumatic."
U's organization has made great strides in recent years in the battle to reduce preventable medication errors like those that continue to stick in his mind today. Steps have been taken to restrict the availability of potassium chloride ampules that previously were widely accessible in hospital wards across Canada. The institute has worked alongside Health Canada to press manufacturers on drug package design so that products such as potassium chloride concentrate are clearly distinguishable from other medication.
ISMP Canada has also waged a campaign to reduce the risk of hospital errors involving the anti-cancer drug vincristine following a number of tragic mishaps where the medication was injected into a patient's spinal fluid instead of into an intravenous drip. It has also pushed for a national plan to roll out bar coding for medication throughout the country as a step toward standardizing the delivery of that medication and reducing the chance of human error. U is proud of the support and discretion that his organization provides to health care workers across the country who report errors.
"One of the things that we do and do well is to connect with providers, the actual staff, nurses, pharmacists or even physicians who contact us, either through phone or email or our reporting program, to tell us their story," U says. "And again we keep that information confidential, encourage them to talk to me or ISMP Canada, and then we will use their information to try and correct the system.
"That is also their goal. The only reason they're calling me is out of altruism, they want to share this story so that nothing of this kind will happen again."
Everyone is human, no system is infallible and errors will happen, U says.
"I think this kind of support, a personal call and reassurance that we can do something about it, goes a long away. Nothing goes into a black hole from the provider's perspective because that's what they want. They want changes, they want support."
While nobody in healthcare goes into work wanting to make a mistake, acknowledging those mistakes when they occur, however difficult that might be, is best for everyone.
"Whatever you need to do, tell yourself that you have done your best and try to report it, and collectively we can make sure of change," U says. "And don't be afraid."