Building a Safer System: A 17 Year Journey

To celebrate the second annual World Patient Safety Day, we are proud to premiere the documentary, Building a Safer System, showcasing the 17-year impact of the Canadian Patient Safety Institute. The film is followed by an expert panel discussion of the theme, Health Worker Safety – A Priority for Patient Safety.

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[a.g.]

This 2 tier system in Alberta is often not transparent. I learned I paid for unnecessary spinal surgery and that the surgeon did not document the surgical alteration of the L3 spinal processes. A private pay MRI in BC identified the incorrect surgical level.

I relocated to Calgary for continuity of care and hoped to pursue graduate studies. I encountered multiple barriers rather than receiving the expected continuity of care. I advised the surgeon that something is wrong below my waist and paid for an MRI in Calgary and would learn more than a year later that I was misdiagnosed with sacral insufficiency fractures.

I had multiple diagnostic reviews of multiple images through AHS and at no time did anyone identify this misdiagnosis . These needs to be a review of the "SECOND OPINION DIAGNOSTIC REVIEW PROCESS". Clinicians may have: 1. stopped looking for additional abnormal findings on a study once an initial probably diagnosis was identified. 2. They sought evidence to support a diagnosis hypothesis already made, and to ignore evidence refuted that hypothesis. 3. The radiologist had fixed upon an early impression, and failed to adapt or changed that view, discounting any subsequent information that may conflict. 4. After having identified a first abnormality, the radiologist failed to continue to look for additional abnormalities. 5. The radiologist identified abnormalities but into attributed the abnormalities to the wrong cause. 6. The radiologist used uncritical reliance on previous report in reaching a diagnosis leading to the perpetuation of error two consecutive studies.

These reviews spanned all of 2020 and I had to leave Alberta to authentic care. Albertans need to be protected and harm needs to be disclosed in a timely manner.