Saskatchewan first with mandatory reporting of medical errors
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* Amy Jo Ehman

New legislation in Saskatchewan — the first of its kind in Canada — will soon require mandatory reporting of all medical errors to the province's Department of Health. Currently, “adverse event” reports are submitted voluntarily. The regulations, which take effect this spring, are expected to result in advisories to health personnel.

On a separate front, the College of Physicians and Surgeons of Sask- atchewan has become the first in Canada to require physicians to report mistakes to patients.

“The primary purpose is to learn from experience,” Duncan Fisher, assistant deputy minister of health, said of the government's action. “We want to develop a system that isn't just a bureaucratic reporting process, but one where we can actually provide valuable information that will have an impact on the care people receive.”

Fisher said individuals will not be singled out, and the new system will not apply sanctions or penalties. “It is not a performance indicator,” he said. “We don't want to focus on blaming people for making an error. The focus is on learning and on improving the system.”

The college supports the initiative. “It's an inherent part of professional integrity to be honest with people,” said Dr. Dennis Kendel, the registrar. “If people are told quickly and honestly about an error, they might not be happy about it but they're much more likely to accept it than if they discover it later and it seems apparent that it's been covered up.”

The college's own policy stresses that physicians must provide full disclosure of errors to patients who might not otherwise have suspected one; mistakes made during surgery or in a laboratory are examples. It also requires the disclosure of errors that were caught and corrected, and it applies to incidents that occurred in the past and were never disclosed.

“People have the right of redress through legal claims if they've suffered irreparable damage, and they would have no way of initiating such claims unless they have information about the error,” said Kendel. In other jurisdictions with mandatory disclosure requirements, he said, the number of lawsuits has increased but the overall amount of cash awards has decreased.

This Saskatchewan college says it was prompted to act by a call for full disclosure from the Canadian Medical Protective Association.

Kendel agrees that some physicians will have a hard time admitting mistakes to their patients. However, he said there is no place for paternalism in an increasingly complex health care system that is providing more opportunities for things to go wrong. “Errors do happen much more often than we once thought,” he said. — *Amy Jo Ehman*, Saskatoon