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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.

Perhaps the Central East Local Health Integration Network should also be questioned, Brady said. "That's their job. To make sure money is being spent properly." Part of the Canadian Health Coalition, the local health coalition aims to preserve Canada's medicare system and promote universal public health care.

Agriculture, Food and Rural Affairs Minister and Peterborough MPP Jeff Leal had just returned to the city late Wednesday afternoon when he learned of the news from the hospital. "It is a re-calibration of their financial statements involving a significant amount of money and the process will be ongoing," Leal said.

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.

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.”

Patients can also incorrectly take their chemotherapy drugs at home because they don’t understand the complicated instructions, adds Melissa Griffin, who has been conducting research on oral chemotherapy delivery with the HumanEra project. With the drug Temozolomide, a brain cancer drug, for instance, “there are multiple different strengths of the pills that patients have to put together to make up the dose,” she says.

Another reason dosing errors can occur is that patients can be given the wrong dose due to an error by the prescriber or pharmacist distributing the drug. Education for patients and family members, along with better standards to avoid prescribing errors, reduce the risk of over- or under-doses of chemotherapy. But the safety standards, as well as the level of education and support patients on oral chemotherapy receive, differs vastly depending on where they live.

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.

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

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

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.”

Stephen Pratt, an anesthesiologist and chief of the division of quality and safety in anesthesia at the Beth Israel Deaconess Medical Center in Boston. From a health care system perspective, supporting second victims may reduce health worker turnover and lead to better patient care.

Bottom line – what they have promised here is a rounding error in the overall health care budget.

The report details vulnerabilities in the system and the costs of inaction: Emotional abuse, bullying, and even physical threats are often accepted as “normal” conditions of the health care workplace.  Production and cost pressures in health care have reduced intimate, personal caregiving to a series of demanding tasks performed under severe time constraints, detracting from what should be joyful and meaningful work. More full-time employee workdays are lost in health care each year (due to illness or injury) than in industries such as mining, machinery manufacturing, and construction.