Incidents in the health system: 316 deaths in one year

1116992(Quebec) Three hundred and sixteen people have died as a result of a fall or an error in medication and treatment at a health facility in Quebec last year. This is according to the 2014-2015 report of the National Register of incidents and accidents occurred during the delivery of health care, published by Quebec a few days before Christmas.

The number of deaths rose by 15% compared to the previous year, a statistic that the Ministry of Health only explain and about which he urged caution. The situation is “unacceptable”, denounces the Regroupement provincial committees of users. Overview of the report and reactions.

More than 400,000 incidents and accidents

481,000 “adverse events”, small incidents of no consequence to accidents resulting in death, have been reported in 266 health facilities between 1 April 2014 and 31 March 2015. They occurred mainly in nursing homes and hospitals. People aged 75 and over are the most frequent victims.

The five major incidents

Just over a third of incidents and accidents are falls. We counted 167,551 last year. There was also 141 608 related errors medication and 24 898 other treatment-related. The report also notes 12 427 cases of abuse, assault, harassment or intimidation of a patient. Here are five key incidents last year:

Falls: 34.8%
Errors related to medication: 29.4%
Errors related to medical treatment: 5.2%
Diagnostic laboratory test: 4.9%
Abuse, assault, harassment and intimidation: 2.58%
Diet: 0.6%
Accident related to Hardware: 0.6%
Accident related to the equipment: 0.3%
Laboratory diagnostic test: 0.3%
Diagnostic imaging test: 0.3%
Distribution of incidents and accidents according to age
75 and over
65-74 years
45-64 years
19 to 44 years
0-18 years
“Permanent consequences” for 651 people

For 84.7% of accidents and incidents last year, there were no consequences for the patient. But in 14.9% of cases, the patient suffered “temporary consequences”. He had to receive first aid or stay longer in hospital, for example. And in 651 other cases (less than 1%), the accident resulted in the death of a user or “permanent consequences for its physiological functions, motor, sensory, cognitive or psychological.”

Deaths caused primarily by falls

The 316 deaths occurred last year were caused mainly by a fall. It can be inferred that they were elderly in many cases.

Causes of death

Chute: 54.8%
Treatment-related errors: 5.7%
Errors related to medication: 3.16%
Other: 34.18% (respiratory obstruction and suicide are the most common, according to the report)
Deaths up 15%

The number of deaths increased by 15% in one year. There had been 275 in 2013-2014. The increase is significant, especially when one considers that the total number of incidents and accidents increased, he, under 2%. The Ministry of Health is running out of answers on the phenomenon. “I have no explanations to give over that. Is it because more deaths are reported “by the publication’s institutions in the national registry? “It yardstick there more awareness among institutions for the more possible events are declared, says a spokesman, Noémie Vanheuverzwijn. In recent years, the institutions did not transmit all of their data; some do not provide at all. “Since publication in publication, some institutions fail to transmit all of their data, it is difficult, if not foolhardy, to perform an analysis or comparison of trends” does one note in The report. He also noted that for the same reason, there is likely more accidents and incidents in health institutions than the number which appears on the National Register. “The data should be interpreted with nuance, since the results likely reflect underreporting explained by the gradual implementation of the system, the progressive participation of institutions and difficulties some of them for data entry in the last month covered by the period covered by the report. ”

Faulty taken establishments

Among the 266 network health facilities, four did not submit complete data in the National Register. Four others have not participated in the exercise, thus violating an obligation under the law. “Work is done with the directions of the institutions to identify the problem and fix it so that the data appear in future reports,” reads the report. The four offending establishments:

Eldercare Floralies de Lasalle (Montreal)
Addiction rehabilitation center in New Departure (Montreal)
CLSC Naskapi (North Shore)
Eldercare Valeo (Montégérie)
Preventable deaths

“There are too many deaths in the network. This is unacceptable. And for me, those are things that are preventable. Especially when it comes to medication. Half the deaths are related to falls while we know the causes of falls. The first is a poor fit of the medication of a person. “- Pierre Blain, director general of the Regroupement provincial committees of users. He criticizes the government and institutions to promptly implement the recommendations of a working group, Viligance for the safety of care, dating from June 2014. The recommendations were aimed at improving the prevention of falls and medication errors to .

An action plan is being implemented, meets Quebec

“The safety of beneficiaries of the health system is a key element and we will spare no effort to reduce risk related incidents and accidents. The establishment of a register and the annual publication of a report reflect the interests of transparency within us. Following recommendations from the reports of the Compliance Group, we are implementing a corporate action plan. “- The office of the Minister of Health Gaétan Barrette, who was not himself available for an interview yesterday. Note that the departmental action plan was made public there are more than a year, in October 2014.

The Stopru