British Columbia’s provincial health officer, Dr. Perry Kendall, recently declared a public-health emergency because of an epidemic of deaths from opioid drug overdose.
There is no question there has been a large and rapid increase in these deaths. In fact, more people now die from overdoses than from motor-vehicle crashes, so rightly this is getting a lot of attention. But it is one small part of a bigger problem that is much more deserving of the title “public-health emergency.”
I touched on this recently in a column on the marketing of pharmaceutical drugs, when I noted that the opioid drug overdose problem is partly rooted in over-prescribing by physicians. This in turn is rooted in the marketing activities of the pharmaceutical industry, which is in turn but one small part of a much bigger problem: Medical error and other adverse effects of health care.
This is not a new concern. An authoritative study on adverse medical events in Canada, published in the Canadian Medical Association Journal in 2004, found that “in 2000 … 9,250 to 23,750 deaths from adverse events could have been prevented.” That made preventable adverse events among the most important causes of death in Canada, comparable to deaths from such conditions as stroke, unintentional injury or pneumonia. It is important to note that these deaths were considered to be preventable.
More recently, an American study published last month in the British Medical Journal found that roughly 250,000 deaths in the U.S. in 2013 — nearly one in 10 deaths — resulted from a medical error, and specifically what they called “preventable lethal events.”
That made medical error the third-largest cause of death in the U.S., after heart disease and cancer.
But the problem is even bigger than this, because both studies were only looking at hospital in-patient errors, and did not include errors in the primary- and community-care components of the system. There is no reason to believe that the situation in B.C. would differ markedly from those and other Canadian and U.S. studies.
So while I am sympathetic to the crisis of overdose deaths, I suggest the provincial health officer needs to step back and look at the wider issue of medical error and adverse events, and declare them to be a public-health emergency, too. Moreover, he needs to expand the definition of adverse events to go beyond just medical error.
In a 2004 article in the Annals of Internal Medicine, Dr. Steven Woolf argued that medical error is a larger issue than what he called “lapses in safety” (mistakes in the provision of care). He includes the failure to systematically provide to the entire population proven effective clinical preventive services such as immunizations, cancer screening or the detection and control of high blood pressure.
These, he argues, are sub-sets of a larger problem: “Lapses in quality” that arise from “flaws in the design and operating procedures of systems and organizations.” This would include failing to provide access to care for those who are in need or failing to provide reminders for overdue services.
As has often been noted, if my auto mechanic can remind me when my car is due for service, why can’t the health-care system remind me when I am due for routine preventive service?
Indeed, it is these system failures that present the greatest challenge. One of the most influential organizations in the field is the U.S.-based Institute for Health Improvement; its chronic-disease management system has been particularly influential here in B.C. One of its persistent themes is that “every system is perfectly designed to achieve the results it delivers.”
We have some of the tools to address these issues, including the B.C. Patient Safety and Quality Council, and the Lifetime Prevention Schedule, the first systematic approach to clinical prevention in Canada, but they need to be prioritized and their capacity increased. Because right now, we have a system that is perfectly designed to yield high levels of adverse events and lapses in quality, with significant impacts on the health of the people of B.C.
Surely this constitutes a public-health emergency.
Dr. Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy.
