The Pediatric Cardiac Surgery Inquest Report



Hierarchy of the effects of errors

Errors, in and of themselves, are worthy of assessment, regardless of consequences. Although some errors may not have negative consequences, there is, in effect, a hierarchy or evolution of the effects of errors. This hierarchy starts with errors that give rise to simple incidents, which may evolve into more serious events called 'critical incidents', which may then evolve into 'complications' or 'accidents'.

Errors are unplanned events that could, or do, lead to negative consequences. Humans commit errors, not because of any moral failing, but because humans are flawed beings, working in flawed systems that together contribute to the commission of errors.

Errors, coupled with a patient's medical condition and other flaws in the system, can result in an incident. The occurrence of an incident simply implies that the course of care, such as a cardiac operation, did not go as planned or predicted.

Should an incident occur, given the right circumstances, it may then contribute to the development of a 'critical incident'. The transition to critical incident is characterized by the development of the potential for harm to a patient, but not actual harm. This is the threshold point before a complication occurs. Another term for a critical incident is an 'adverse process'.

A critical incident may then further evolve into a complication or 'accident'. (Use of the word 'accident' should not be taken to mean that the problem arose 'accidentally' or by chance.) Only when the outcome of a case is not as planned or predicted, and the patient has suffered some harm, is an accident said to have occurred. Another term used in medicine to describe an accident is an 'adverse outcome'.

Nevertheless, it is important to understand that in medicine, errors only rarely lead to complications and so usually do not get past the 'incident' stage. For that reason, perhaps, incidents and even critical incidents are rarely recorded. When they are recorded they may be dismissed, or not pursued, because they did not produce negative results or consequences. Critical incidents are often termed 'near misses' and the fact that they did not give rise to complications is often ascribed to 'good fortune'. It should be understood however, that the lack of complications (or 'good fortune') ought to have no bearing on the question of whether or not an error occurred. All that the phrase 'good fortune' really means is that those discovering the incident were unable (or unwilling) to determine the reasons for the 'near miss' and acted solely on the basis that the lack of a negative result was enough. Similarly, to dismiss the occurrence of complications as simply 'bad luck' is to forfeit the opportunity to determine some of the underlying contributory factors to the problem.

When investigating a problem with patient care, it is not enough simply to determine 'what' happened: for example, the patient died. Nor is it enough to determine only 'how' the patient died: for example, from being given the 'wrong' drug because of human error. The most important, and often ignored step, is to determine 'why' the patient died and the underlying contributory system and human factors to the making of the error. (Some examples include confusing labelling of the drug, inadequate lighting, two patients with the same name, an over-worked and fatigued doctor, and lack of an assistant.)

Everyone can learn when studying their own and others' errors. Improvements in the system would be made more rapidly, however, if errors, incidents and critical incidents were more closely and systematically examined.


The importance of early reaction to error

One of the facts that clearly arises from these proceedings is that there was a clear lack of a timely and critical examination in the hospital of the events that occurred in the operating room during the surgical procedures that have been the focus of this report.

The M & M Rounds, which were often described in the evidence as a means by which mistakes could be identified and discussed, failed in several other respects. These rounds involved several other people in the hospital over and above the team members involved in the operations. They also did not have the appropriate focus as will be seen later in this discussion. More importantly, the rounds were not scheduled at times that allowed for or required full participation by all team members.

While it is possible that the Wiseman Committee was intended to provide such a process, it failed to do so in several respects, all of which have been discussed in detail elsewhere in this report.

There was also a report issued by the Paediatric Death Review Committee of the College of Physicians and Surgeons that assessed the deaths of these twelve children and which concluded that four of these deaths might have been prevented through better medical management. That review did not occur until long after the events in question. However, that review did not involve the program participants in a team-like setting, nor allow for the sharing of results in a manner that contributed to the improvement of the team's overall ability to perform their tasks or improve their collective and individual abilities to treat their patients better. As well, that review did not consider the errors and 'near misses' that did not have fatal consequences.

Furthermore, the Williams and Roy review in 1995 was not intended as a review of error. It was intended as an overall assessment of the program. There was no attempt by those reviewers to look at each or any of the cases.

What was clearly missing at the HSC in 1994, therefore, was a process that allowed team members to comfortably and collectively assess and evaluate the events that occurred in the operating room in a manner that contributed to improvements in the way that the patients were treated. Because of this deficiency, problems and concerns developed to the point that by the time of the death of the twelfth child, the level of confidence among those within the program was at its lowest. It is safe to say that most members of the team probably felt anxiety over whether or not they could perform even the simplest procedure without complication.

If the hospital is to consider renewing the program or participating in a similar program in a different form, it needs to seriously consider developing a better process for members of surgical teams and programs to learn from the mistakes that they will inevitably make. Even if the hospital does not move toward re-establishing a similar program in the future, a mechanism that focuses members of a surgical team on the process of learning from mistakes would be of benefit to the hospital generally. Therefore, such a mechanism will be discussed.



Current Home - Table of Contents - Chapter 10 - Hierarchy of the effects of errors
Next Human factors analysis
Previous The investigation of human error
Section 1 Chapter 1 - Introduction to the Issues
  Chapter 2 - Pediatric Cardiac Issues
  Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment
  Chapter 4 - The Health Sciences Centre
Section 2 Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993
  Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
  Chapter 7 - The Slowdown
May 17 to September 1994
  Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
  Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
Section 3 Chapter 10 - Findings and Recommendations
Appendix 1 - Glossary of terms used in this report
Appendix 2 - Parties to the Proceedings and counsel
Appendix 3 - List of witnesses and dates of testimony
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