Patient Safety and Quality Improvement in Health Care Where does the profession stand? O Dr. Don Nixdorf has been the ex- ecutive director of the BCCA since 1985, was BCCA and BCCC presi- dent from1982-1985, governor and secretary-treasurer of the CCA from 1987 to 1989 and served as chair of the Commission on Chiro- practic Education (Canada) from 1994 until 1999. From 1982-1991 he was staff chiropractor/consul- tant to the Workers’ Compensa- tion Board of B.C. and has been a participant in National E-Claims Standards since 2001. He is a for- mer committee member of the BC government Health Information Standards Council. Dr. Nixdorf is also co-author ofSquandering Bil- lions: Health Care In Canada, which analyzes the causes of the crisis in health care and strategies for its survival. He can be contacted at [email protected] n April 12-14, I attended Canada’s Forum on Patient Safety and Quality Improve- ment in Toronto. The volume of information, and magnitude of the impact of this issue on the public, was a new experience for me, regardless of the exposure I’ve had to countless government, research and profession-specific meetings. The conference’s attendees and their orga- nizations are too numerous to list, but should be reviewed at www.patientsafetyinstitute.ca/ English/news/canadaForum/Pages/default.aspx by all boards and members to appreciate the scope and future role for safety and outcomes discussions. Notable speakers included the Deb Matthews, Ontario Minister of Health; Jim Ea- ton, National Health Service UK; and Dr. Jason Leitch, National Clinical Lead for Safety and Improvement Scottish Government. A brief review of the conference will dem- onstrate that the first and major awareness of injury and death is associated with hospital and related institution-based care. However, confer- ence discussions clearly indicated that this was just the most easily observable environment. Primary care, or that occurring in physician clinics, is understood as equally a concern and will be the subject of focus and action at a future date. In this report, I will attempt to review some of the salient features of the conference. I must mention that I also include some of my own impressions, herein. A NAKED ACKNOWLEDGMENT It was stated by keynote speakers at the conference that health care is safe, but not safe every day for every patient. The opening presentation, in fact, reported on thousands of needless deaths associated with preventable infection. The largest prevention measure, in 2010, was the act of washing hands, an easy activity that, studies have shown, actually has a very low compliance rate amongst health care workers! But, the full range of specific examples, and identification of all preventable mistakes causing injury and death, was beyond the scope of this, and likely any, conference, regardless of organizations involved. The fact is, there are too many preventable health- care mistakes, as documented by a variety of publications and reports, including those authored by coroners and physicians, among others. My first reactions from reading over 90 poster presentations – primarily from hos- pital-based clinicians, staff, and researchers – listening to presenters and speaking with attendees from across Canada were combined sadness/depression and hope. The sad- ness was from the repeated documentation of the almost countless injuries and lives lost arising directly, and indirectly, from the actions of health-care providers of all categories. (The numbers are actually even higher since, due to lack of awareness and under-report- ing of daily mistakes, some cases are not represented in the literature). This was openly 30 • CANADIAN CHIROPRACTOR | MAY 2010 www.canadianchiropractor.ca Don Nixdorf, DC feature
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