Patients Pledge to Fight Medical Errors throughout the Americas

First Regional Workshop on Patients for Patient Safety Held in San Francisco

Washington, D.C., May 12, 2006 (PAHO)—Victims of medical error and patient advocates from North, Central and South America concluded a three-day meeting in San Francisco this week pledging to raise awareness about the devastating impact of medical errors and adverse medical events and to organize efforts to improve patient safety in their home countries.

Participants from Argentina, Chile, Costa Rica, Mexico, and Peru joined counterparts from Canada and the United States for the first Pan American Health Organization/ World Health Organization (PAHO/WHO) workshop on Patients for Patient Safety. Patients for Patient Safety is one of six programs of the World Alliance for Patient Safety, established by WHO in 2004 to advance patient safety practices and policies across the world.

"Patients and their families are the ones who suffer when things go wrong," said José Luis Di Fabio, head of PAHO's Technology and Health Services Delivery program. "Health professionals may at first resist their involvement in corrective efforts, but we have to listen to what they say and learn from their experiences."

"The problem of bad medical care is, from my point of view, alarming," said Evangelina Vásquez, whose infant son suffered brain damage as a result of a series of medical errors in Mexico. "Besides my own case, I know so many people who've had so many bad things happen to them."

Vásquez's son Uriel suffered neonatal jaundice shortly after his birth, but his mother's pleas for medical attention were dismissed by health care providers. The untreated jaundice produced irreversible brain damage known as kernicterus. Vásquez took her case to Mexico's National Commission on Human Rights and won a favorable decision. She is now working to advance the cause of patient safety in her country and internationally as a Patient Safety Champion of the World Alliance for Patient Safety.

Canadian Ryan Sidorchuk, now coordinator of a Patient Safety Advisory Council for the Winnipeg Regional Health Authority, lost his 2-year-old daughter three years ago in part as a result of medical errors during her treatment for cancer. "The health care team focused almost completely on the disease to be treated and on the treatment they had chosen. As her parents, we knew something was wrong, but we were laypeople, and they somehow could not see or hear what we were saying. They used the wrong protocol of chemotherapy on my daughter, and by the time they realized their mistake, her condition was so poor it was too late."

Failures in patient safety exact an enormous human toll around the world. In the United States alone, medical errors cause more deaths each year than breast cancer, car accidents or AIDS, according to a 1999 study by the Institute of Medicine. In the United Kingdom, data show that one in 10 patients suffers an adverse event while hospitalized. In Australia, the rate is 16.6 percent, and similar rates are found in New Zealand and Canada.

The situation is worse in developing regions such as Latin America, though data are more difficult to come by. WHO estimates that the risk of health care associated infection is 2 to 20 times higher in developing than in developed countries.

In addition to human error, health care systems are fraught with systemic problems. For example, thousands of patients are given the wrong drugs each year-sometimes with fatal results-because hand-written prescriptions and hospital orders are difficult to read. Medications are sometimes confused because labels are too similar in appearance. More common are lapses in hygiene and infection control because of inadequate training, poor quality control, or lack of personal protective equipment.

Alfonso Maldonado, of Peru, lost his 13-year-old son Augusto to what he says was a series of medical errors and reprisals, including a poorly performed biopsy, a delayed pathology report, denial of care, overmedication, and withholding of treatment.

"My son is with God now," says Maldonado, "but we continue to struggle for all the children and old people who experience even worse things, because their voices are not heard."

Wilfredo Pino, a Peruvian physician and university professor, personally experienced the consequences of medical error, including a nearly fatal hospital-acquired infection that kept him in intensive care for a month.

"I have been through some very difficult moments that have given me a much better understanding of patients and have made me much more humane, and I try to practice that and teach it to my students."

Alicia Herrera, from Mexico, suffered extreme pain and permanent disfigurement and disability as a result of faulty administration of anesthesia prior to a tooth extraction. She authored a book about her ordeal, The Face of Medical Negligence: Do You Want to See My Face?

"My life changed overnight," says Herrera. "I lost my health, my job, and my love life."

The Patients for Patient Safety workshop was held in conjunction with this week's annual meeting of the National Patient Safety Foundation, which brings together health care providers, health product manufacturers, researchers, patient advocates, regulators, and policymakers to develop and implement strategies for advancing patient safety in the United States.

"Patient safety must be a collaborative effort," said Sue Sheridan, whose son and husband both suffered from medical errors, and who now leads the Patients for Patient Safety program of the World Alliance. "The challenge is not to place blame or to punish people, but to prevent errors from occurring in the first place. That requires more transparency in health care systems and more willingness on the part of health care providers to confront problems."

Other organizations that provided support for the PAHO/WHO Patients for Patient Safety workshop include Consumers Advancing Patient Safety (CAPS) and the Canadian Patient Safety Institute (CPSI). PAHO was established in 1902 and is the world's oldest public health organization. It serves as the Regional Office for the Americas of the World Health Organization and works with its member countries to improve the health and quality of life of all the people of the Americas.

LINKS:

• World Alliance for Patient Safety
• National Patient Safety Foundation
• "Patient Safety: Do No Harm," article in Perspectives in Health magazine