Nearly all of the sepsis cases reviewed by the Canadian Medical Protective Association (CMPA) in a recent investigation involved healthcare workers, reveal findings that have been shared with The Canadian Press.
The CMPA looked at 163 forensic sepsis cases concluded between 2011 and 2020, namely cases where patients went to a higher body (such as the courts or the College of Physicians) because they were dissatisfied with the care received.
Difficulty diagnosing sepsis and communication problems are the two main issues that have been identified by the CMPA.
Sepsis is an extreme and life-threatening reaction of the body to a severe infection that can lead to organ failure or dysfunction. Prompt management is crucial to improving patient outcomes, but the problem can be difficult to pinpoint.
“You can have two patients who have the same age, the same risk factors, and one of these patients will see a problem (of sepsis) and the other will be completely correct”, summarized the administrative director of the CMPA, Doctor Armand Aalamian.
Factors related to CMPA member physicians were noted in 160 of the 163 files reviewed, including inadequate monitoring or follow-up, or failure to perform an examination or procedure, or to administer a medication.
Insufficient assessment of conditions was identified in 80% of cases. Half of the patients involved in the 163 cases analyzed had visited outpatient clinics several times before their symptoms progressed to sepsis, and in nearly 40% of cases intensive care was required during the ‘hospitalization.
Patients suffered serious harm, such as amputation or brain damage, in one-third of cases.
Sepsis, Dr. Aalamian recalled, “can present in the context of a minor infection that turns into sepsis very quickly.”
“Or it could be a matter of weeks before it gets really problematic,” he added. It’s important to look at all the symptoms of someone who comes back often (see a doctor). It’s necessary […] keep sepsis in mind, because it’s not always the first thing doctors think about. »
Communication problems have also been identified in many files, whether between health professionals or between doctors, patients and their families.
The CMPA’s retrospective analysis aimed to identify potential warning signs of severe sepsis risk, patient characteristics and health care elements that contributed to delays in sepsis diagnosis, and opportunities of improvement.
The Association intends to use the data from this survey to develop an educational tool for physicians.