When Danica Terziski's infant son Daniel died following cardiac surgery, she thought it was the hand of fate. But when Danica learned that Daniel was one of 11 children to have passed away during, or soon after, surgery in the same unit at the Winnipeg Health Sciences Centre.she "realized it wasn't destiny. It wasn't fate. It was medical error."
A landmark 1999 report by the Institute of Medicine estimated that up to 98,000 Americans die of medical mistakes every year – killed not by their conditions, but by the system designed to treat them.
The Winnipeg infant deaths led to the longest inquest in Canadian history – and the coroner's report didn't just blame the unit's relatively inexperienced surgeon. It pointed to systemic flaws that prevent mistakes from being recognized and corrected.
This hard-hitting documentary features interviews with advocates, victims and hospital administrators, many of whom make exactly the same point. Those interviewed extensively include two of America's top names in patient safety: Dr. Donald Berwick (Barack Obama's pick to head Medicare and Medicaid), and Dr. Lucian Leape, who co-authored the 1999 IOM article and now heads an institute named for him at the National Patient Safety Foundation.
Both argue that medicine has much to learn from the aviation industry. Leape notes that airline deaths declined four-fold over a ten-year period. The odds of dying in a commercial airline crash are now 1 in 3 million – and each accident is followed by a thorough government investigation. Meanwhile, hospital patients have a 1 in 300 chance of dying as a result of their care, and investigations are exceedingly rare.
Some errors are the result of poor design, such as a cancer drug that is fatal when injected into the spine. (A new delivery system is being planned that would make such injections impossible.) Others, including misdiagnoses, are more complex. In KILLED BY CARE we meet Ryan Sidorchuk, whose daughter died after her cancer was misdiagnosed. Now a patient advocate, Sidorchuk describes his family's experience with the medical system as "focused institutionalized ignorance."
KILLED BY CARE makes the case that most doctors and nurses are well-meaning and competent – but patients will continue to die unnecessarily unless major changes are made to healthcare delivery systems. It lays bare a medical culture in which healthcare workers are scared to apologize, victims are left without support, and whistle-blowers are silenced by their employers.
"Pilots make as many mistakes as doctors," says Leape, "but the planes don't crash. They have systems that intercept those mistakes, whereas we don't."
Produced for the Canadian Broadcasting Corporation's highly acclaimed and award-winning series The Nature of Things, KILLED BY CARE was originally released in 2004 – but its message is just as potent today. In fact, the number of people who die as a result of medical accidents in the US every year is believed to have increased over the last decade.
More than a decade after the ground-breaking IOM article,KILLED BY CARE helps explain why the culture of medical systems has made them so slow to change.
"A worthy companion and successor to the IOM report...This timely film had all the advantages of an emerging mass of documentation and the initial outcomes of funded research into medical mistakes...KILLED BY CARE is highly recommended for all public, academic, and high school audiences." —Charles J. Greenberg, Cushing/Whitney Medical Library, Yale University, for Educational Media Reviews Online
"Using authorities, it makes a good case that medicine is not doing nearly as good a job relative to its oath to 'do no harm' and that far too many die from making mistakes during treatment-mistakes that go uninvestigated and therefore get repeated. ...an excellent means to call attention to the problem." —Science Books and Films