Nova Scotia medical mistakes registry goes on line

The Nova Scotia government has followed through on a promise, posting its medical mistakes registry on the health department website.

According to the government website, making the information public "raises the level of accountability – and demonstrates a commitment to transparency and openness. The goal is to share lessons learned and prevent the event from happening again."

For the first six months of 2014, 27 serious adverse events were reported. Twenty-one of those incidents resulted in "adverse health effects leading to death or serious disability" while a patient was being cared for at a facility in Nova Scotia, including three incidents where a patient died or was injured after a fall while being cared for by a district health authority or the IWK.

Other mistakes include five patient suicides or attempted suicides, three serious diagnostic errors and six cases of severe bedsores.

"But there's not necessarily causation between one and the other," said chair of the Nova Scotia quality and patient safety advisory committee , Catharine Gaulton. She said the information instead aims to "trigger a review to see whether there is in fact an opportunity for improvement."

Details of the incidents were withheld for patient safety.

Mistake victims

Sharon Fisher was the victim of a diagnostic mistake in 2013.

Her breast was removed after a lab error mixed up her biopsy results with another patient with cancer.

"Oh no, you never get used to it," she says. "I still haven't looked in a mirror and I won't."

Her case prompted the province to create the new policy on reporting serious adverse events.

The error against Fisher is the kind of incident that would be reported on the new medical mistakes registry.

Before this year, the nine health authorities across the province had their own methods of dealing with mistakes that led to serious disability or death.

The new policy now dictates incidents from all authorities be reported to the Department of Health and Wellness within 12 hours.

Tanya Barnett has long been pushing for a documented approach to medical mistakes and will be taking a close look at what is released Thursday.

Barnett lost her 17-year-old daughter Jessica after test results were read in error by specialists. That led to a faulty diagnosis.

"The trend may be that one particular physician is not doing a very good job," she says. "They need to know that, to take matters into their own hands to fix that."

Barnett posted a YouTube video that chronicled her daughter’s misdiagnosis at the IWK Health Centre. It has been viewed 37,000 times.

Too few mistakes?

Personal injury lawyer Ray Wagner says 27 seems like a low number of incidents for the first six months of 2014, but thinks it will empower patients.

"It enables patients to be able to look at the data and say 'I'm going in to this particular location for this particular procedure. There have been some problems with, for instance, post-operative care, maybe there's been a higher infection rate. I'm going to be more vigilant, I'm going to ask more questions,'" he says.

Both Wagner and Barnett are already questioning the registry and how the numbers are recorded.

According to the government's website, every year the nine health districts and the IWK have about about 100,000 inpatient and day visit surgeries and procedures, 665,000 emergency room visits, 100,000 ground and air ambulance transports, and more than a million diagnostic imaging tests.

Death of Mohammed Eshaq

Another patient reflected in the medical mistake records is Mohammed Eshaq, who fell to his death from his apartment balcony after he ran away from the Nova Scotia Hospital.

Eshaq fell from the 10th floor of his south-end Halifax apartment after officers broke into his apartment on Feb. 3 while at large from a psychiatric hospital in Dartmouth. He later died from his injuries.

At the time, his father Gamal Bineshaw questioned how police handled the final encounter with their son.

In February, Bineshaq said he believed his son was frightened by the loud knocking on the door and the family wonders why his family or the Mobile Mental Health Crisis Team wasn't called.

Now he says, he's glad the record of his son's death due to a medical mistake has been made public.