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In Canada, it’s estimated between 56,000 and 63,000 people die as a result of medical errors and hospital-acquired infections – the second leading cause of death.

preventable medical errors are going to get worse if the Ontario government cuts hospital budgets and thousands more beds

To find out more about the June 4 conference go to: http://www.ochu.on.ca/conferences_conventions.html

To register for the conference or for more information, please visit the OCHU website: http://www.ochu.on.ca/conferences_conventions.html.

speakers and contributors will be discussing possible next steps to be taken in the healthcare community

the conference will address issues such as for-profit care and factory medicine, staffing ratios, under reporting, shiftwork and working conditions, bullying in the workplace

William Charney, is a nine-time published author of healthcare safety books. He has also published more than 30 peer-reviewed articles in the field. For five years, Mr. Charney was a safety officer at the Jewish General Hospital in Montreal, Quebec. For ten years, he was the director of environmental health at the Department of Public Health in San Francisco. Then for five years, he was a safety coordinator for the Washington Hospital Association. For the last ten years, he has been a consultant in the field of occupational health.

Their trust would be further hit. Within two weeks, the Star reported that health-care companies are allowed to mix drugs for hospitals without federal or provincial oversight, prompting top health officials — Ontario health minister Deb Matthews and federal health minister Leona Aglukkaq — to scramble to close that regulatory grey area.

Since the crisis, all the hospitals involved have stopped outsourcing gemcitabine and cyclophosphamide mixtures and brought it in-house, mixing their own medications.

The federal government has new rules defining who can be a drug producer, adding that any facility supervised by a licensed pharmacist can do the job. The province has said that hospitals can only purchase drugs from accredited suppliers.

The Ontario College of Pharmacists has passed legislation that allows it to inspect any premises where a pharmacist works — not just licensed pharmacies.

All of the changes taken together would have seen Marchese Hospital Solutions still able to supply drugs as it did but subject to inspection by the college.

This week Jake Thiessen, the founding director of the University of Waterloo school of pharmacy, submitted a final report of his investigation into the issue. There has been no formal indication when it will be made public. Hospital administrators say they have been told it will be two to three weeks before they or the public see this report.

There is very little clinical evidence to indicate what might happen to a cancer patient who receives an underdose of chemotherapy.

At the same time, many of the more recent advances in chemotherapy have been in drugs that alleviate side effects like nausea.

In an oncology pharmacy, strange is not good. And on March 20, one week before Marley’s last cyclophosphamide treatment, Craig Woudsma, a 28-year-old pharmacy assistant, and a colleague at the Peterborough Regional Health Centre, had a bad feeling.

In this case, it was a shipment of new gemcitabine chemotherapy bags that required refrigeration, according to the label. Previous batches, from a different supplier, had not.

When preparing the solution, staff at Marchese Hospital Solutions, in Mississauga, Ont., dissolved the medication into a pre-filled 100 mL bag of saline. These bags typically contain between 3 to 20 per cent more solution than 100 mL,

The new bag’s label did not contain enough information for him to accurately mix the patient’s dose. He needed to know the specific concentration.

Woudsma noticed more differences. The bags from Marchese only had a total volume and concentration on the label — 4 grams of gemcitabine in 100 mL of saline — instead of the specific concentration, the amount of drug per single mL of saline, as the old bags indicated.

“I told the pharmacist in the area. And then it kind of went above me at that point ... They came to me saying, this is kind of a big deal; teleconferencing with the minister of health, that kind of stuff,” said recently, sitting on the front steps of his red-brick, semi-detached home in the village of Millbrook, Ont. “It’s kind of a foreign concept, to think that what we do, in our corner of the hospital, is going to get that kind of exposure.”

referred to in the industry as overfill, included to account for possible evaporation.

People have asked Woudsma why he was able to catch a problem that went undetected at other hospitals for more than a year. Simple, he says. He had something to compare it to.

The company’s pharmacy workers did not remove the known overfill when mixing the medication because they thought each bag was going to a single patient

This means that the bag Woudsma was holding contained 4 grams of gemcitabine in more than 100 mL of solution. The concentration of the medication wasn’t what the label would have made him think. It was weaker than advertised.

The hospital had switched that very day to a new supplier — Marchese Hospital Solutions. A bag of the old supply from Baxter CIVA was still on site.

Medbuy, a group purchasing company for hospitals, starting in 2008, had a contract with Baxter Central Intravenous Admixtures to provide drug-mixing services. The two drugs in question, cyclophosphamide and gemcitabine, were outsourced because they come in powder form and are tricky to mix. It takes about four hours to reconstitute them in liquid, and in that time they must be shaken every 20 minutes.

As that contract was about to expire, Medbuy issued a request for proposals for drug-mixing services: Baxter CIVA, which wanted its contract renewed, Quebec-based Gentes & Bolduc and Marchese all stepped forward.

Marita Zaffiro, president of Marchese, testified at Queen’s Park that the Medbuy contract did not indicate the hospitals wanted the labels on these drugs to cite a specific concentration. The reason she included it that way in the RFP was simply to show what could be done.

The details of the new arrangement remain known only to Medbuy. It was founded in 1989 to get better deals for hospitals buying products like scalpels, bed pans and even some medications in bulk. The company’s 28 member hospital organizations in Ontario, New Brunswick and Prince Edward Island spent a combined $626-million on contract purchases in 2012.

Sobel ran the calculations in his office. For a single patient to require a 4,000 mg dose of cyclophosphamide, on a common breast cancer treatment regime, that patient would need to be about 7 feet tall and weigh 2,200 lbs.

“The chance of 1,200 patients getting 4,000 mg exactly — it’s just impossible.”

Four Marchese pharmacists who played a role in the new contract work revealed to the Queen's Park committee in June that they had either limited or no background in oncology.

Marchese Hospital Solutions began as Marchese Pharmacy, a Hamilton-area community drugstore that expanded beginning in 1998 when Zaffiro became president. In 1999 the company obtained a contract to supply the Hamilton Niagara Haldimand Brant Community Care Access Centres, business they did until the contract expired in 2011, shortly before it was awarded the Medbuy contract.

It lost the CCAC contract in 2011, shortly before the Medbuy deal, and shed employees. Fifty-seven were either laid off or left the company during this troubled time, according to internal newsletters. But then things started looking up.

Zaffiro attempted to get accreditation for the site, according to her Queen’s Park testimony, approaching both the Ontario College of Pharmacists and Health Canada, neither of which took steps to regulate the fledgling business because each thought the other had jurisdiction.

Medbuy, Marchese and Jake Thiessen have maintained that cost was not a factor in the error. Marchese’s bid on the request for proposal came in at about a quarter of the cost of previous supplier Baxter Corporation. Bags from Marchese cost from $5.60 to $6.60; Baxter charged $21 to $34.

CEO David Musyj thinks about what went wrong. The problems, he says, go far beyond Marchese and Medbuy. “All of us are culpable,” he says. “We could have done some things internally that could have prevented this. We could have weighed the bags when they came in.”

Hundreds of thousands of patients on B.C. waiting lists know that role is not being fulfilled. The health minister and premier recently admitted that patients were waiting inappropriately long times, and a health region spokesperson reported some "life-saving" procedures were being delayed. Provincial health commissions were the brainchild of Tommy Douglas, who believed they should be chaired by doctors and never subject to political influence. But the MSC is always chaired by a politicallyappointed civil servant. Douglas supported premiums and felt they made the public cost-conscious, creating a sense of individual responsibility. He would never have condoned the practices of raising premiums to compensate for fiscal failures, nor reporting low-income earners, delinquent with their payments, to collection agencies. The commission is wasting health care funds as it displays contempt, in terms of its fiscal and social accountability, toward taxpayers.. In one example of carelessness and incompetence, I received cheques from them totalling hundreds of thousands of dollars, for services on patients that I had never seen. I also received confidential personal information on hundreds of patients unrelated to me or our clinic. When informed of their error, they responded: "Just mail them back." They were not inclined to investigate.

In Canada, health providers are compelled by law to share confidential patient files with government employees armed with the right to inspect and copy patients' files. Your health record is considered public property; you cannot block government access. Consent is not needed, and you are not notified when Big Brother is looking. Privacy rights have been legislated away. I witnessed a defeated provincial cabinet minister's medical file being reviewed by a newly elected government. In the 1989 tainted blood inquiry, Justice Horace Krever was "shocked by the inadequate laws, the abuses of confidentiality, and the fact that so many people - except the patient - had access to medical records." Little has changed.

The MSC is also charged with defining what services are "medically necessary" - and therefore publicly insured. They have never created a definition, but have arbitrarily designated clearly essential services such as ambulance, drugs, physiotherapy, artificial limbs, and dentistry as unnecessary, creating a true two-tier structure of care. The government's last action in delaying our constitutional challenge on patient rights resulted from a "last minute" discovery of 300,000 documents they were legally bound to provide. After a delay of more than seven years, the plaintiffs in the coming June trial will confirm that the Supreme Court of Canada's 2005 finding - that patients are suffering and dying on waiting lists - applies in B.C. Supporters of a system that limits timely access are complicit in such outcomes.

Our public sector health system (MSC included), is grossly overstaffed with non-clinical workers. A 2011 study revealed that Canada has 11 times as many public health bureaucrats per capita as Germany, where there are no waiting lists. Canada has 14 ministries of health, each with bloated bureaucracies and commissions scavenging dollars that should go to patient care. The mentality that cost inefficiencies can be balanced by increased taxes or "premiums" is responsible for our escalating charges. Independent health groups in Europe rated Canada as last in value for money compared to hybrid public-private systems that have accessible public systems. The Commonwealth Fund, a non-profit foundation focused on issues affecting lowincome groups, ranked Canada 10th of 11 health systems in developed nations.

What specific changes would I incorporate if I were minister of health? Apart from incorporating the best practices of other hybrid systems (including private-sector competition), I would dismantle the ministry and its committees and commissions. Then I would resign. The finance ministry could fund patients directly (thus empowering them), and also assign budgets to the newly emancipated, self-regulated health organizations, allowing them to cater directly to patient needs. Maybe our June constitutional court challenge will point us in that direction. Dr. Brian Day is an orthopedic surgeon, medical director of the Cambie Surgery Centre, and a former president of the Canadian Medical Association.

Dr. Brian Day says bureaucrats at the Medical Services Commission sent him cheques totalling hundreds of thousands of dollars for services on patients he had never seen.

Within hours of emergency surgery to drain "brown, foul-smelling liquid" and excise dead tissue, and four days after her 45th birthday, Ms. Smith was dead. "She kept yelling at me, 'I know my body, I know there's something wrong in my stomach and nobody wants to listen to me. And I'm going to end up dying here,' " said Kym Dyck, her sister-in-law. "She died the most horrible, painful death anybody could suffer, and nobody would listen to her and reach out to her." Ms. Smith's tragic demise was more dramatic than many cases of hospitalacquired infection (HAI). Necrotizing fasciitis is a frightening, but rare, complication. Still, about 8,000 Canadians a year die from bugs they contract in facilities meant to make them better, while many more see their hospital stay prolonged by such illness.

She likely did not know that most surgical-wound infections arise from bacteria patients carry into hospital on their skin, which can then sneak inside through incisions, especially when infection-control safeguards are not optimum. As early as the day after her operation, the Métis woman began to complain of pain in her abdomen, only to be told by nurses that she simply needed to walk about, Ms. Dyck recalls. Some of that suffering is reflected in her patient charts, obtained by the family and provided to the National Post. On Oct. 1, she complained of gastrointestinal bloating and discomfort; the following day, heartburn, bloating and slight nausea, the records note.

Yet after years of well-intentioned work and millions of dollars spent on combating the scourge, the details and extent of the problem remain murky. No national statistics, for instance, document the number of surgicalwound infections like Ms. Smith's, one of the most common types of hospitalacquired pathogens. A federal agency now publishes rates of sepsis, or blood infection, at individual hospitals, but their methodological value is a matter of debate. Government tracking of worrisome, drug-resistant bacteria is patchy and of questionable practical use, say infectious-disease physicians. "There is no question that at a national level, both our surveillance for hospital-acquired infection and our surveillance for anti-microbial resistance is not serving our needs," said Allison McGeer, an infectious-disease specialist at Toronto's Mount Sinai Hospital. "[And] we know, very substantially, that you can't fix what you're not measuring."

"You could sit and call every hospital in the country, and ask them when was the last time they cleaned the sink in the [neonatal intensive care unit] and how they cleaned it, and you'd get nothing but blank stares." Health care is paying much more attention, at least, to the HAI problem than it did a decade ago, said Dr. Michael Gardam, infection-control director at Toronto's University Health Network. After heavy media coverage of the mostly hospital-based severe acute respiratory syndrome (SARS) outbreak and deadly hospital infestations of Clostridium difficile, said Dr. Michael Gardam, infection-control director at Toronto's University Health Network. As health-care-related infection became a very public affair, hospitals started hiring more experts, encouraging hand-washing and generally striving to prevent infection, rather than just treating it after the fact as an unavoidable cost of doing medical business. Dr. Gardam's hospitals have even begun characterizing hospital-acquired infections as adverse events, akin to more traditional medical error. Whether because of such measures or not, Ms. Smith had few fears when she entered St. Boniface on Sept. 30, 2013, for an operation for uterine fibroids, her family says.

Meanwhile, important lessons about how diseases spread inadvertently within health facilities often come to light in fits and starts. Two hospitals in Toronto and one in Quebec, for instance, announced independently in the late 2000s that they had discovered contaminated sinks were the source of separate, deadly outbreaks of infection. Some word of the episodes got out through specialized medical journal articles, academic conferences and sporadic news stories. But there is no systematic way of disseminating such information across the system, said Darrell Horn, a former patient-safety investigator for the Winnipeg Region Health Authority. "It's just totally loosey-goosey," he said.

The program's focus is drug-resistant bacteria, the increasingly familiar methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE) and C. difficile. It is based, though, on a sampling of just 57 teaching hospitals, a fraction of the country's 250 or so acute-care hospitals. The SARS outbreak, for instance, erupted at a community hospital that is not part of that network. Infectious-disease doctors have long complained that it takes too long for the data those hospitals submit to the Agency to be posted. "If I want to know what's happening with MRSA, I call my friends," said Dr. McGeer. More complete, and easier to access, is the system developed by the European Centre for Disease Control, says Lynora Saxinger, an infectiousdisease specialist at the University of Alberta. It not only tracks drug-resistant bugs, but matches those stats with the use - or possible over-use - of antibiotics, considered the main cause of the problem. The latest concern of infectiousdisease specialists is a class of antibiotic-defeating organisms known as carbapenem-resistant Enterobacteriacaeae (CRE), a "game-changer," said Dr. Saxinger. The death rate is as high as 50%. CRE is part of the public health agency's surveillance system, meaning those 57 hospitals submit their numbers, but Dr. McGeer said all acutecare hospitals in Canada should have to report them. Meanwhile, "the last CRE outbreak ... I heard about it on the news," said Dr. Saxinger.

There is no evidence Ms. Smith was infected with a drug-resistant organism, but by the time she went in for emergency surgery, it appears little could have saved her. Indeed, once begun, necrotizing fasciitis has a 70% death rate. Early the next morning, her blood pressure had sunk, the telltale black of more dead tissue had spread around her side to her back and she went into cardiac arrest, dying minutes later. The hospital investigated the incident and assured the family that lessons learned from it would be passed on to staff - and help future patients, says Ms. Dyck. Mr. Horn says his experience across Canada suggests it is unlikely those lessons will be shared with anyone else in the health-care system, or the public. Meanwhile, Ms. Dyck says the sight of doctors and nurses fruitlessly attempting to revive her sister-in-law - her abdomen left open as part of the flesh-eating treatment - remains etched in her mind, as is the thought it might all have been prevented. "What I witnessed, I was traumatized by for months and months," she said. "It was just a terrible, terrible, painful death. And she knew she was going to die, that's the worst thing." National Post tblackwell@nationalpost.com

To see the first part of the series, Inside Canada's world of medical errors, go to nationalpost.com

Not only is there more data, analyzing these scans is not as simple

another factor is the plethora of scans and images on record which make it easy to scrutinize the work of doctors after the fact.

But Jean-François Leroux, whose Montreal law firm represents nine women considering or already taking legal action against a Quebec radiologist who missed dozens of breast cancers, says these were not isolated incidents. "It was really the absence of any control of the quality of the procedures," he said.

The Quebec College of Physicians has recommended better oversight of radiologists, digitized mammograms to make them easier for others to consult and more uniform standards for private clinics.

Among significant changes: 1. Develop clear guidance on when and how hospitals should use QCIPA to avoid the large variation in how the act is currently used. 2. Amend the act to ensure appropriate disclosure to patients and families following a critical care incident so they are informed about the results of an investigation, including what happened and what measures would be taken to prevent future incidents. 3. Establish an appeal mechanism for the investigation of critical incidents so in circumstances where patients or families are not satisfied with a hospital review, they can request an investigation from an independent body, possibly the Office of the Patient Ombudsman. 4. Establish a publicly available database or registry that contains information about all of the critical incidents investigated in Ontario hospitals, including the type of incident, the causes and the recommendations to prevent future incidents. 5. Patients and families must be interviewed as part of the process of investigating critical incidents and then be fully informed of the results.

Shepter's story illustrates a problem that extends far beyond a single California nursing home. ProPublica and PBS "Frontline" have identified more than three-dozen cases in which the alleged neglect, abuse or even murder of seniors eluded authorities.

For more than a year, ProPublica, in concert with other news organizations, has scrutinized the nation's coroner and medical examiner offices [1], which are responsible for probing sudden and unusual fatalities. We found that these agencies -- hampered by chronic underfunding, a shortage of trained doctors and a lack of national standards -- have sometimes helped to send innocent people to prison and allowed killers to walk free.

If a senior like Shepter dies under suspicious circumstances, there's no guarantee anyone will ever investigate.

"a hidden national scandal."

Because of gaps in government data, it's impossible to say how many suspicious cases have been written off as natural fatalities.

In one 2008 study, nearly half the doctors surveyed failed to identify the correct cause of death for an elderly patient with a brain injury caused by a fall.

Autopsies of seniors have become increasingly rare even as the population age 65 or older has grown. Between 1972 and 2007, a government analysis [2] found, the share of U.S. autopsies performed on seniors dropped from 37 percent to 17 percent.

"father was lying in a hospital bed essentially dying of thirst, unable to express himself -- so people could have a nice, quiet cup of tea."

"We're where child abuse was 30 years ago," said Dr. Kathryn Locatell, a geriatrician who specializes in diagnosing elder abuse. "I think it's ageism -- I think it boils down to that one word. We don't value old people. We don't want to think about ourselves getting old."

A study published last year in The American Journal of Forensic Medicine and Pathology found that nearly half of 371 Florida death certificates surveyed had errors in them.

Doctors without training in forensics often have trouble determining which cases should be referred to a coroner or medical examiner.

State officials in Washington and Maryland routinely check the veracity of death certificates, but most states rarely do so

there has to be a professional, independent review process

a public, 74-bed facility

As the chief medical examiner for King County, Harruff launched a program in 2008 to double-check fatalities listed as natural on county death certificates. By 2010, the program had caught 347 serious misdiagnoses.

Of the 1.8 million seniors who died in 2008, post-mortem exams were performed on just 2 percent. The rate is even lower -- less than 1 percent -- for elders who passed away in nursing homes or care facilities.

Some counties have formed elder death review teams that bring special expertise to cases of possible abuse or neglect. In Arkansas, thanks to one crusading coroner, state law requires the review of all nursing-home fatalities, including those blamed on natural causes.

Thogmartin said "95 percent" of the elder abuse allegations he comes across "are completely false," and that many of the claims originate with personal injury attorneys.

Decubitus ulcers, better known as pressure sores or bed sores, are a possible indication of abuse or neglect. If a person remains in one position for too long, pressure on the skin can cause it to break down. Left untreated, the sores will expand, causing surrounding flesh to die and spreading infection throughout the body.

Federal data show that more than 7 percent of long-term nursing-home residents have pressure ulcers.

"Very often, that is the way these folks die," he said. "It is a preventable mechanism of death that we're missing."

"Occasionally, there are elderly people who are being assaulted. But this issue of pressure ulcers is a far, far bigger issue, and really nationwide."

a new state law requiring nursing homes to report all deaths, including those believed to be natural, to the local coroner. The law, enacted in 1999, authorizes coroners to probe all nursing-home deaths, and requires them to alert law enforcement and state regulators if they think maltreatment may have contributed to a death.

"It was a horrible place,"

investigations led state regulators to shut down the facility, in part because of the home's failure to prevent and treat pressure sores

prompted Medicare inspectors to start citing nursing homes for care-related deaths and to undergo additional elder-abuse training.

Still, nursing homes inspections are not designed to identify problem deaths. The federal government relies on state death-reporting laws and local coroners and medical examiners to root out suspicious cases

They found such problems repeatedly at Riley's Oak Hill Manor North in North Little Rock.

A 2004 review of Malcolm's efforts by the U.S. Government Accountability Office concluded that the "serious, undetected care problems identified by the Pulaski County coroner are likely a national problem not limited to Arkansas."

staffing in homes is a constant challenge. Being a caregiver is a low-paying, thankless kind of job. (at one time you could make more money flipping burgers than caring for our elderly- priorities anyone??) With all the new Medicare cuts, pharmacy companies who continue to overcharge facilities for services, insurance companies who won’t be regulated, our long-term facilities are in for a world of hurt- which will affect the loved ones we care for. Medicare cuts mean staffing cuts- there are no nurse/patient ratios here- meaning you may have one nurse for up to 50 residents. Scary? You bet it is!!  Better staffing, better care, everyone wins.

Lets not just blame the caregivers. Healthcare and business do not mix. When a business is trying to make money, they will not put the needs of patients and people first. To provide actual staffing (good-competant care with proper patient to caregiver ratios) the facilities would not make money.

Medical buildings often have standard benchmarks — basing the number of examination rooms, for example, on the expected volume of patients. Ms. Brandenberg and her team instead used C.P.I. to map out common paths that patients, staff members, supplies and information would flow through. They worked in an empty office building, using cardboard mock-ups of surgical sites, recovery rooms, anesthesia areas and waiting rooms. Fifty staff members then play-acted various scenarios to test the design’s effectiveness. The final design reduces walking distances and waiting times for patients by grouping related facilities together and creating rooms that can be used for more than one purpose. The hospital was able to shave 30,000 square feet and $20 million off of the new building

Last year, amid rising health care expenses nationally, C.P.I. helped cut Seattle Children’s costs per patient by 3.7 percent, for a total savings of $23 million, Mr. Hagan says. And as patient demand has grown in the last six years, he estimates that the hospital avoided spending $180 million on capital projects by using its facilities more efficiently. It served 38,000 patients last year, up from 27,000 in 2004, without expansion or adding beds.

checklists, standardization and nonstop brainstorming with front-line staff

The program, called “continuous performance improvement,” or C.P.I., examines every aspect of patients’ stays at the hospital

The system is just one example of how Seattle Children’s Hospital says it has improved patient care, and its bottom line, by using practices made famous by Toyota and others. The main goals of the approach, known as kaizen, are to reduce waste and to increase value for customers through continuous small improvements.

“The health care industry could be on the verge of an efficiency revolution, because it is currently so far behind in applying operations management methodologies,” says Professor Litvak.

All medical centers, especially larger ones, would have significant return on investment by using operations management techniques like C.P.I., says Eugene Litvak, president and chief executive of the Institute for Healthcare Optimization and an adjunct professor of operations management at the Harvard School of Public Health.

Similar methods are now in place at other hospitals and health systems, including Beth Israel Deaconess Medical Center in Boston, Park Nicollet Health Services in Minneapolis and Virginia Mason Medical Center, also in Seattle.

TO be sure, not everyone believes that factory-floor methods belong in a hospital ward. Nellie Munn, a registered nurse at the Minneapolis campus of Children’s Hospitals and Clinics of Minnesota, thinks that many of the changes instituted by her hospital are inappropriate. She says that in an effort to reduce waste, consultants observed her and her colleagues and tried to determine the amount of time each of their tasks should take. But procedure times can’t always be standardized, she says. For example, some children need to be calmed before IV’s are inserted into their arms, or parents may need more information. “The essence of nursing,” she says, “is much more than a sum of the parts you can observe and write down on a wall full of sticky notes.”

one-day strike by the Minnesota Nurses Association against six local health care corporations, including her employer, partly in protest of lower staffing levels her union thinks have resulted from hospitals’ “lean” methods

the Lean Enterprise Institute

George Labovitz, a management professor at Boston University, says there are limits to performance-improvement methods in hospitals. “Human health is much more variable and complex than making a car,” he said, “so even if you do everything ‘right,’ you can still have a bad outcome.”

Joan Wellman & Associates, a process improvement consulting firm in Seattle

examine the “flow” of medicines, patients and information in the same way that plant managers study the flow of parts through a factory

In a typical workshop at Seattle Children’s, a group of doctors, nurses, administrators and representatives of patients’ families set aside a 40-hour week to work through C.P.I. methods. They plot each “event” a patient might encounter — like filling out forms, interacting with certain staff members, having to walk various distances or having to wait for assistance — and brainstorm about how each could be improved, or even eliminated.

it never ends

Standardization is also a C.P.I. cornerstone. Last year, 10 surgeons at Seattle Children’s performed appendectomies, and each doctor wanted the instrument cart set up differently. The surgeons and other medical staff members used C.P.I. to come up with a cart they all could use, reducing instrument preparation errors as well as inventory costs.

It was a jurisdictional grey area, with both the college and Health Canada unable to agree on who was responsible for the facility.

The crisis has also raised questions about whether the privatization of health care has gone too far. The bags containing the chemotherapy drugs were filled with too much saline, watering down the medication by as much as 20 per cent. Some patients received the drugs for as long as a year. It's a grave warning that privatization has to stop, said New Democrat health critic France Gelinas.

"As those new companies spring up all over to do for-profit services for hospitals, the government basically stayed asleep at the switch," she said.

"They never looked at who was picking up this work to make sure that the level of oversight, the level of quality assurance that we had before were being transferred over. The work got transferred, the oversight did not."

A pharmacy expert, Jake Thiessen, will review the province's cancer drug system, Matthews said. A working group that includes doctors, Cancer Care Ontario, Health Canada and others are also looking at the problem.

ealth Canada and the Ontario College of Pharmacists are working to close that ga

The number of "medical incidents" - hospital jargon for treatment errors - has spiked, said the nurse, who agreed to be interviewed on condition that his or her name not be published for fear of reprisals. The nurse said the hospital has prohibited stafffrom speaking to journalists about problems in the ER. In perhaps the most glaring case, a patient who was "gushing blood" arrived by ambulance in the ER and was supposed to undergo a transfusion immediately, but the blood supply was not ready even though it had been ordered in advance 30 minutes earlier, the nurse said. The girl ended up dying because of the severity of her injuries, not the delay in receiving the blood transfusion, but the case nonetheless illustrates the risks involved, the nurse added.

A second source described other "botched" cases, including a boy with a badly fractured femur "who sat in the ER for (eight) hours without it being set until someone actually looked at the X-ray." The are multiple causes for the problems, said the ER nurse and the second source - a lack of staff and unfamiliarity with the new medical equipment, lab technicians who haven't been trained in processing pediatric blood samples, and glitches in the facilities. And all those problems have occurred amid cost-cutting imposed by the provincial government.

"It's a zoo, it's dangerous," the ER nurse told the Montreal Gazette. "Before we moved in, we were told three things: the new ER was going to be more patient-centred; the doctors, nurses and clerks would be working better together; and it was supposed to be more comfortable. I haven't seen any of those things. Nobody works together because we're all preoccupied with our own things. We're running around like dogs. For me, it's falling apart. Patients' lives are in danger."

Officials at the Montreal Children's denied that lives are in jeopardy, but acknowledged that there have been problems in the processing of lab samples, some staffing shortages as well as glitches. At the same time, the medical team has been treating an unseasonably high number of patients with serious illnesses, said Dr. Harley Eisman, director of the emergency department. "I think we all recognize that moving to a new house is a big deal for everybody, and actually, our emergency department has had some significant cases," Eisman said. "We've dealt with many sick children over the past couple of weeks. We've had pretty brisk numbers as well. It hasn't been a quiet summer for us."

Lyne St-Martin, nurse manager at the Children's ER, said although "we have occasional shortages (of nurses), for the most part our quotas are met and our nursing staffis rather stable." Still, St-Martin warned that staff and patients will have to make adjustments for months to come at the Glen site, following the Children's move there from its old address on Tupper St.

"I do want to highlight that we transitioned three months ago, and that in speaking to other hospitals that have actually moved as well, they spoke about a one-year transition time where there is a very steep adaptation, and it will continue for several months to come," St-Martin said. "So none of this is surprising." Among the problems identified by the ER nurse:

At one point, water started pouring from a pipe in the ceiling of one of the treatment rooms. Staff closed the room and protected the medical equipment, but the leak hasn't been repaired yet. In the meantime, staffcan't use the sinks in the adjoining rooms to wash their hands. Eisman said there are other treatment rooms available and the ER flow hasn't been hampered. An emergency psychiatric room for agitated adolescent patients - some of whom are suicidal - has a bathroom that locks from inside and can't be opened by staff, the nurse said. There have been two cases where patients locked themselves in the bathroom and security was called but the guards arrived late. Eisman said that there is now a protocol in place to post a guard next to the bathroom in such cases. He added that glitches like the bathroom lock are being addressed quickly, although some parts are on back order.

Some of the lab techs, who used to work at the old Royal Victoria Hospital, have not been trained fully to process blood samples for children, resulting in delays as long as four hours for medical issues that must be addressed immediately, the nurse said. Eisman responded that "when we opened we certainly raised issues about lab performance. We opened a line of communication with the lab and were immediately on it and the lab performance has improved dramatically."

The Children's ER is consistently understaffed by nurses, and yet more than a dozen have not yet been fully trained to perform all tasks in the department, and there have been delays "in working up infants for signs of meningitis," the nurse said. What's more, many ER nurses are assigned to accompany patients on other floors, resulting in longer waits for emergency patients. As a consequence, frustrated parents have ended up shouting at nurses in the ER. Some of the nurses have reacted by seeking solace in the bathroom and crying in private for up to half an hour.

St-Marin said the ER nurses have been trained to deal with parents who are in crisis, and added "that our numbers show that (patients) are not waiting longer. In fact, we're tending to our sicker patients faster." She did not cite any statistics. The ER nurse accused the McGill University Health Centre of mismanagement, saying it had been planning the Montreal Children's move for years but has not trained staffproperly in using some of the new equipment. For example, some X-ray technicians continue to use portable X-ray machines rather than the new equipment in the ER. The MUHC has also balked at paying nurses to work overtime, yet the ER has ordered great quantities of rarely-used IV filters at $500 a box that sit mostly unused on shelves, the nurse added. aderfel@montrealgazette.com twitter.com/Aaron_Derfel

up to 63,000 Canadians die each year from medical mistakes - the equivalent of three jumbo jets crashing each week.

The main culprits, Charney said, are staff overburdened with too many patients, over-long shifts and difficult working conditions.

ideal staff to patient ratios are 1 to 4, while typical Canadian ratios are 1 to 9

My story is relatively brief. Six years ago, shortly after completing my residency in Rochester, N.Y., I opened a solo family medicine practice in what had become my adopted hometown. I had a vision of cultivating a practice where patients felt heard and cared for, and where I could provide a full-spectrum of family medicine care, including obstetrics. My practice embraced the principles of patient-centred collaborative care. It employed the latest in 21st-century technology. After five years of constant fighting with multiple private insurance companies in order to get paid, I ultimately made the heart-wrenching decision to close my practice. The emotional stress too great. My spirit was being crushed. It broke my heart to have to pressure my patients to pay the bills their insurance companies said they owed. Private insurance never covers the whole bill and doesn't kick in until patients have first paid down the deductible. For some this means paying thousands of dollars out-of-pocket before insurance ever pays a penny. But because I had my own business to keep solvent, I was forced to pursue the balance owed.

Doctors deal with this conundrum in different ways. A recent New York Times story described how an increasing number of doctors are turning away from independent practice to join large employer groups (often owned by hospital systems) in order to be shielded from this side of our system. About 60 per cent of family GPs are now salaried employees rather than independent practitioners. That was a temptation for me, too. But too often I've seen in these large, corporate physician practices that the personal relationship between doctor and patient gets lost. So I looked for alternatives. I spoke with other physicians, both inside and outside my specialty. We invariably ended up talking about the tumultuous time that the U.S. health care system is in - and the challenges physicians face in trying to achieve the twin goals of improved medical outcomes and reduced cost.

I knew Canada had largely resolved the problem of delivering affordable, universal care with a publicly-financed single-payer system. I also knew Canada's system operates more efficiently than the U.S. system, as outlined in a landmark paper in The New England Journal of Medicine. So I decided to look at Canadian health care more closely. I liked what I saw. I realized I did not have to sacrifice my family medicine career because of the dysfunctional system on our side of the border. In conversations with my husband, we decided we'd be willing to relocate our family so I could pursue the career in medicine that I love. I'll be starting and growing my own practice in Penetanguishene on the tip of Georgian Bay this autumn. I'm excited about resuming my practice, this time in a context that is not subject to the vagaries of backroom deals between monied, vested interests. I'm looking forward to being part of a larger system that values caring for the health of individuals, families and communities as a common good - where health care is valued as a human right.

I hope the U.S. will get there some day. I believe so. Perhaps Canada will help us find our way. Emily S. Queenan, MD, resides in Rochester, N.Y. She is an adviser with EvidenceNetwork.ca.

The Canadian Food Inspection Agency reported an outbreak of highly pathogenic H5N1 bird flu at a farm in Chilliwack, British Columbia. The same backyard poultry flock also had cases of the H5N2 strain confirmed in December.

Health Canada launched a new Drug and Health Product Register to provide consumers with easy access to information on medicines and vaccines. The Web tool allows users to search for information by brand name, active ingredient or drug identification number. Currently, it only provides information on the top 100 prescribed brand-name and generic drugs.

Quebec passed a controversial health care bill to merge boards at individual health institutions into 28 regional boards. The province expects the reorganization will save some $200 million annually, but critics fear it will put anglophone health services at risk. Health care unions and doctors’ federations denounced the Liberal government for invoking closure to force Bill 10 into law.

Alberta Health Services CEO Vickie Kaminski announced new hiring restraint and wage freezes, after the provincial government said it will slash 9% from its annual budget to cope with a $7-billion revenue shortfall. Kaminski also said that “more aggressive” cuts are coming, pending a review of health-worker cellphone use, sick days and severance payments.

British Columbia has Canada’s healthiest population and, along with Ontario, ranks higher than most advanced countries in the Conference Board of Canada’s first health report card that compares Canada and 15 peer countries. BC ranked third overall, after Switzerland and Sweden, across a variety of health indicators. Newfoundland and Labrador and Canada’s three territories received the worst grades.

An Ontario medical marijuana company is urging Canadians to return or destroy a batch of highly potent pot. Peace Naturals Project Inc. voluntarily recalled several lots of its Nyce N’EZ strain after an independent lab found that it contained as much as 13.7% tetrahydrocannabinol — much more than the 9.07% listed on the product label.

Quebec confirmed 10 measles cases linked to a recent outbreak at Disneyland in California. So far, the outbreak has involved 114 cases in seven American states. Eight confirmed cases in Ontario are likely unrelated to the US outbreak.

Nova Scotia patient advocates called for an end to ambulance fees. The province billed patients some $12.2 million for ambulance service in 2013/14. According to the Nova Scotia Citizens’ Health Care Network, those fees deter people from calling an ambulance in emergencies, “adding costs to the health system due to increased complications.”

Three Toronto colonoscopy clinics have had hepatitis C outbreaks since 2011, the Star has learned.

The authorities responsible for investigating the spread of infection and inspecting the clinics — TPH and the College of Physicians and Surgeons of Ontario, respectively — kept the outbreaks secret.

“The minister of health has to realize that this push into the community is not safe. It won’t be safe until we have in place much more robust oversight,” she said.

The MPP for Nickel Belt also wants the province to suspend the downloading of hospital services into the community and place a moratorium on the creation of any new clinics until a new oversight body is created to ensure public safety.

She is calling on the province to remove the CPSO as regulator of such clinics — known as “out-of-hospital premises” — charging that the outbreaks show the organization is failing in its duties to uphold quality of care and to be transparent, and is placing patients at risk.

None of the clinics offered up anyone to be interviewed, but all three provided written statements. They all expressed concern for the health and recovery of the patients, said they co-operated fully with investigations and emphasized that they are committed to ensuring outbreaks never occur again.

Tom Closson, former president of the Ontario Hospital Association and a supporter of moving some services from hospitals to community clinics, is in agreement that outbreaks should be made public. “I believe that public confidence in the health-care system will improve faster if people know that patient safety is being addressed in an open and transparent manner rather than through keeping errors hidden,” he said.

Gélinas called on the province to suspend the movement of hospital services to the community clinic sector. “To me, it rings alarm bells as loud as can be. Minister, you cannot continue down this path until you put in place strong oversight, strong accountability and strong transparency,” she said in an interview, referring to Hoskins and his government’s ongoing expansion of the community sector.

Gélinas said the NDP is not opposed to community care as long as it is provided in not-for-profit facilities that have strong oversight, accountability and transparency. “We are a long way from this in Ontario and good people are paying the price, most often with their health and well-being,” she warned.

On Friday afternoon, the Star was informed by the CPSO that the college is now in the process of inspecting the three colonoscopy clinics. Earlier in the day, it posted on its public register of out-of-hospital premises that results of the inspections are “pending.”

Asked what the college is doing to stop the multi-dose vial error from repeating itself, Clarke said medical directors of clinics are made aware that compliance with college program standards for out-of-hospitals premises is expected. Among the standards is this requirement: “Multi-dose injectable medications are used for only one patient. If they are not, the rubber septum must be disinfected with alcohol prior to each entry.”