Photo: Jacques Nadeau Le Devoir
“The portrait is rather dark, you don’t see improvement”, note the director-general of réseau FADOQ.
Falls, medication errors, and other accidents that have occurred in the health care network have killed 378 people in 2016-2017. An increase of almost 16 % compared to the previous year. Three-quarters of the deaths occurred in people aged over 75 years : in 63 % of cases, it is a fall that was fatal.
This is one of the findings of the annual report on the incidents and accidents that the department of Health and social Services has filed on its website on December 21.
The events classified as “other” are the second leading cause of death by accident in the network. The suicide or the choking part.
“The portrait is rather dark, you don’t see improvement,” note with concern the director-general of réseau FADOQ, Danis Prud’homme. “To submit a report, it is no longer enough. It is necessary to modernize the process to avoid or minimize these accidents, ” says the voice of seniors in Quebec.
“We see it in the report, the older women are most at risk, it would be necessary to target them and protect them,” also asks Judith Gagnon, president of the Association québécoise de défense des droits des personnes retraitées et préretraitées (AQDR). In fact, 53 % of the incidents and accidents recorded in 2016-2017 in the network, they have consequences or not for the patients, have affected women.
By e-mail, the MSSS has emphasized the Duty that the events that led to a deaths represent only 0.08% of the incidents and accidents reported in the year. People over 75 years of age is “a customer that consumes more care and services than the other age groups, which is hosted on a long-term, or who has the most long stays in a hospital and that is also the most likely to fall because of their fragility,” said the head of media relations Marie-Hélène Émond.
Quebec has formed a working group on the safety of care and services in the last few months. The member must submit a plan of action for the fall of 2018. The 15 members of the committee are from the MINISTRY and different institutions of the network, the majority of the frames.
Half a million of incidents and accidents have been registered in the network, ” said the report, representing a growth of 4 % between 2015-2016 and 2016-2017. The falls, which account for 35 % of the events, and medication errors (27 %) are the most frequent.
The majority of incidents and accidents reported, or 85 %, had no consequence for the patients.
The falls are incidents most common in NURSING homes so that medication errors rank first in the hospital.
“Temporary results” to the patients were recorded in 73 855 cases.
In addition, if the events that caused the death are on the rise, those consequences were “severe and permanent” record a decrease of 9 %, for a total of 323 patients affected.
The authors of the report stress that data must be “interpreted with caution” due to the phenomenon of under-reporting. This is the 9th year that the MINISTRY publishes such a report.
We can’t swear to the reliability of the data, note also Régis Blais. Professor at the School of public health, University of Montreal, in a study published in 2008, it was found that only 15 % of incidents and accidents recorded in the patient records had been subject to a reporting official. “But anyway, the care must improve and we must be able to measure it, he said, either by the number of deaths or readmissions less than 30 days after having her leave, for example. “
The report also reports that the declarations of abuse, assault and harassment have increased over 6 % compared to the previous year. A phenomenon that the MSSS awards an ” increase in the rates of reporting, improved transparency, and the establishment of a culture of reporting within establishments of a network of health and social services, but also within quebec society “.
An increase of nearly 30 % of adverse events in connection with a laboratory test would be due to a situation of under-reporting earlier in the Lanaudière region, which has been halted, according to the MSSS. An interpretation supported in part by the trade union that represents the technicians and professionals of the laboratories in this region. “Every irregularity is noted and reported, confirmed, in the interview, Richard Belhumeur, responding policy for the APTS in the Lanaudière region.
Of the known solutions
The geriatrician David Lussier recalls that the solutions are known to prevent falls and medication errors. The approach adapted to the elderly person, who, since 2011, must be implemented by the institutions, “already contains the necessary recommendations,” he said.
To minimize the risk of falls, several actions are possible : reduce the medication which can cause drowsiness, ensure good lighting, purchase shoes stable, ensuring that the patients wear spectacles, for example. “It’s also necessary for the staff to mobilize the patients as much as possible, so that they maintain their muscular strength. The contention, rather than reducing the incidence of falls, increases, ” says Dr. Lussier.
Medication errors, however, are not foreign to the work overload of the staff, he says. “The pressure that weighs on the people in the network, it can only increase the number of accidents “, is also concerned about Danis Prud’homme.
A professor in the Department of management, evaluation and health policy from the University of Montreal, François Béland asks : with the disappearance of the boards of directors of local health institutions, ” which carries the responsibility to ask questions “, to put in place the fixes ? “It takes a return, on the floors, to the staff, it is very important,” emphasizes the latter.
The DHSS has indicated to the task which ” each institution carries out the analysis of its events and puts himself in the place of the corrective actions to the result of this analysis. “