Knowledge translation and patient safety: The Canadian Adverse Events Study
G. Ross Baker, PhD, University of Toronto
Peter Norton, MD, University of Calgary
Virginia Flintoft, MSc, University of Toronto
The Canadian Adverse Events Study was the first national study of adverse events in Canadian hospitals. Learning from the controversy surrounding similar studies in other countries, the team engaged in extensive knowledge translation (KT) activities throughout the life of the project. Using meetings, web-based communication, and other tools, the team successfully prepared most Canadian stakeholders for the study release, allowing them to develop anticipatory patient safety initiatives. However, upon publication, the policy spotlight quickly shifted to other issues and the long-term commitment needed to create safer health care is still uncertain.
In the spring of 2002, a group of researchers from seven universities across Canada received funding for the Canadian Adverse Events Study,1 the first national study of adverse events in Canadian hospitals. Adverse events are unintended injuries or complications that result in disability, death, or prolonged hospital stay, and are caused by the care that patients receive, not an underlying disease or condition.
Studies of adverse events in other countries have uncovered unanticipated levels of injury—and have often had unexpected effects. Premature announcement of the results of the Australian study by the country's federal minister of health soured relationships between the Australian Medical Association and the federal government for several years. In the United States, the Harvard Medical Practice Study had little policy impact when it was released in 1991. But data from this and other studies became a major news story in 1999 when they were used to create the headline-grabbing press release of a report from the Institute of Medicine (IOM) that stated between "44,000 to 98,000 Americans die in hospitals each year as a result of medical errors."2
Recognizing that the Canadian study would likely have a major impact on health care organizations and professionals, the funders—the Canadian Institute of Health Information (CIHI) and CIHR—worked with the research team to develop a KT strategy designed to prepare Canadian stakeholders for the release of the study.
The KT initiative
Despite the large number of media stories across the country, few Canadians knew much about the adverse events study and its results.
The goal of our KT strategy was to ensure that decision makers, representatives of the health professions, health system managers, and through them, the general public, would be informed of the study and its progress on an ongoing basis. Bringing these groups together would also stimulate each organization's efforts to develop appropriate responses to the study and anticipatory initiatives.
Our activities began with the distribution of a media release to over 1,500 media sources in French and English Canada shortly after funding for the study was awarded. In June 2002, an invitational forum was held in Ottawa for national stakeholders. The focus was on sharing knowledge from similar studies carried out in other jurisdictions, and on defining issues that the study might generate for each organization. CIHI also opened an interactive website to update stakeholders on the progress of the research, which was maintained during the entire project.
A year later, in May 2003, a second forum for the same group of stakeholders was held to provide an update. Participants were also given an opportunity to work in small groups to share information about their patient safety policy planning and intended responses to the upcoming publication of the study. By this time, a number of organizations had already begun policy and educational initiatives designed to improve the knowledge and skills of practitioners, managers and policy makers about patient safety.
On January 12, 2004, the principal investigators of the study, Drs. Ross Baker and Peter Norton, held a webcast to update stakeholders on the progress. Discussions were already underway at this time with the editors of the Canadian Medical Association Journal (CMAJ) to secure an agreement for expedited review and publication of the study.
By mid-April 2004, the study's publication date had been set for May 25, 2004. CMAJ policy was to provide the media with embargoed copies of articles appearing in the journal one week prior to publication. So, on May 20, members of the research team and representatives from CIHI and CIHR briefed the press and key stakeholders on the results. The rate of adverse events for patients in Canadian hospitals was 7.5%, higher than that found in similar U.S. studies, but lower than the rate reported in the Australian study. Just as important was the level of disability and death associated with adverse events that indicated a considerable illness burden.
The paper appeared as scheduled on May 25, 2004 in the CMAJ, but news of the results were leaked three days earlier when journalists from The Edmonton Journal and The National Post broke the embargo. Because these papers had published the key results of the study, reporters from other media outlets had to scramble to write stories on different aspects of the findings. Despite this, the study generated significant media coverage. Drs. Norton and Baker each gave approximately 20 interviews, and more than 28 newspaper stories, 47 radio items, and 19 TV news items were written or broadcast about the study. However, the announcement of the federal election that weekend truncated the news coverage. An analysis by CIHI of the perceptions of major news events in that period discovered that, despite the large number of media stories across the country, few Canadians knew much about the adverse events study and its results.
Results of the KT experience
While practitioners and policy makers were clearly aware of the study and its results, the abbreviated press coverage meant that the public were largely uninformed.
The success of the KT efforts linked to the Canadian Adverse Events Study must be judged by the extent to which key stakeholders were aware of the study results, and by the short- and long-term impacts on patient safety policy initiatives.
In terms of the first question, the level of stakeholder knowledge about the study, the KT efforts were largely successful. Representatives from more than 35 ministries of health, national professional organizations, regulatory and policy authorities, and non-government organizations attended the two stakeholder forums in 2002 and 2003. A large number also participated in the 2004 webcast. Feedback from the early events was used to improve the interaction between stakeholders and the researchers in later meetings and communications.
A count by CMAJ showed that the paper was downloaded from their website more than 25,000 times in the first four days after its publication, a level of activity never before seen at the journal. In the year following publication, the study team authors gave more than 50 presentations at meetings of professional groups and health care organizations, and many more presentations to smaller groups of researchers, managers, and practitioners. However, while practitioners and policy makers were clearly aware of the study and its results, the abbreviated press coverage meant that the public were largely uninformed.
Work by many organizations in the two years between the first stakeholder forum and the release of the study helped to advance patient safety efforts across Canada. Policy initiatives and education programs were developed by many professional organizations, including the Canadian Medical Association, the Canadian Nurses Association, and the Canadian Healthcare Association. Following the study's release, the Canadian Council on Health Services Accreditation (CCHSA) created a Patient Safety Advisory Group (which includes both Drs. Norton and Baker, along with other researchers and decision makers). This group has helped CCHSA develop a set of patient safety goals and required organizational practices that will be implemented in accreditation surveys beginning in 2006. Some observers have also speculated that the launch of the Canadian Patient Safety Institute, recommended by the National Steering Committee on Patient Safety in 2002, was pushed forward in late 2003 because of the need to show a federal government commitment to patient safety prior to the release of the study.
There is also the possibility that our KT efforts had the paradoxical effort of desensitizing some parts of our audience.
While the study has clearly contributed to the awareness and engagement of many organizations, professional groups, and individual practitioners and managers, there is also the possibility that our KT efforts had the paradoxical effort of desensitizing some parts of our audience.
Many organizations worked hard in 2002 and 2003 to develop policies, inform their members, and create media strategies that demonstrated understanding of the issue. In the aftermath of the study's release, and the success of these organizations in their anticipatory efforts, the policy spotlight may have shifted to other concerns. In addition, the federal election was called in the same week as the study's publication, and the issues of waiting times and access were chosen as the key health care platform for the federal Liberal Party's campaign.
Did some organizations believe they had achieved what was needed (or what was possible) for patient safety by May 2004? Did the emergence of waiting times and access as the key health care issues, and the funding that was promised to address them, cut short the focus on patient safety? Did the early involvement of the stakeholder groups in patient safety consultations lead to a waning of enthusiasm for further initiatives once the study results were released?
These questions are difficult to answer. However, recent discussions of the mixed success of the United States in improving patient safety, prompted by the five-year anniversary of the IOM report, suggest that patient safety issues will require continued attention.
Did the early involvement of the stakeholder groups in patient safety consultations lead to a waning of enthusiasm for further initiatives once the study results were released?
Conclusions and implications
The KT efforts centred on the Canadian Adverse Events Study led to a major shift in policy for many Canadian governments and health care organizations. But KT alone has been insufficient to ensure the necessary investment in new resources needed to create safer health care. Other efforts, including the development of the "Safer Healthcare Now!" campaign that targets the reduction of mortality and morbidity from infections and adverse drug events, will be needed to demonstrate and help reduce the gap between current performance and the potential for high reliability health care.
1 Baker, G. R., P. G. Norton, V. Flintoft, R. Blais, A. Brown, J. Cox, E. Etchells, et al. 2004. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. CMAJ 170 (11): 1678-86.
2 Kohn, L.T., J. M. Corrigan, and M. S. Donaldson, eds. 1999. To err is human: Building a safer health system. Washington, DC: National Academy Press.
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