Two decades after a watershed report on errors and unintended injuries in Canada’s hospitals shook the health-care sector, tens of thousands of Canadians continue to be harmed during a hospital stay — many of them, multiple times, new data show.
One in 17 hospitalizations in 2024-2025 — representing more than 153,000 people — resulted in someone experiencing a potentially preventable harm such as a drug error, hospital-acquired infection, a “patient accident” like a fall or radiation burn or some other incident serious enough to require treatment or a prolonged stay, according to the Canadian Institute for Health Information.
In a quarter of those cases, people experienced two or more harmful “events” during their stay.
The data are based on 2.6 million hospital stays. Even then, the numbers don’t capture the full magnitude of the problem. “Near misses,” meaning errors that didn’t reach the patient, aren’t captured. Nor are harms involving people with mental health or substance use diagnoses, harms that occur in emergency departments or harms that start in hospital but aren’t detected until the person is sent home. The report also excludes data from Quebec.
The overall rate of harm has remained at six per cent for the fifth year in a row, higher than pre-COVID years. After spiking in the early pandemic years, “we haven’t really rebounded,” said Melanie Josee Davidson, director of health system performance at CIHI.
“The whole health system is still reverberating from the COVID period and still finding its feet,” she said.
When things go wrong it’s usually down to multiple, complex factors, patient safety experts said. But 21 years after a report known simply as the Baker-Norton report estimated as many as 23,000 people die in Canada’s acute-care hospitals each year from adverse events, “we’ve taken our eyes off the ball,” said Dr. Ward Flemons, a professor of medicine at the University of Calgary.
When the Baker-Norton report — by the University of Toronto’s Ross Baker and Peter Norton of the University of Calgary — came out, “it shook everybody and woke everybody up” from hospital boards and CEOs to medical and nursing stations, Flemons said.
“There was a lot of focus on patient safety, but, like any initiative, it fades over time if there isn’t a constant pounding of the drum.”
Throw in COVID, “and it took focus away from, how do we make current care better, to, how do we keep people alive during a horrible pandemic?”
But Canada is also one of the few countries in the world without a national patient safety plan, efforts at improving hospital safety are “fragmented, and for the most part, voluntary,” and there’s no concerted spotlight on safety, Baker and co-author Leslee Thompson write in
Healthcare Quality
.
Rather, it’s “much like a game of snakes and ladders,” they said. “We make advances, but too often we slide back due to shifting priorities, insufficient funding and resource capacity,” they said.
Concerns have also long been raised about a culture of secrecy that keeps errors from being reported, and full and frank disclosures made to patients and families when they do happen.
“The extent of unsafe care is unknown to patients and the workforce,” Baker and Thompson wrote.
“To advance a safety culture, transparency must be valued, not weaponized.”
Few cases of harm involve true negligence, or, rarer still, a wilful, malicious intent to harm. Bad “outcomes” happen in the best hospitals. However, many harms are avoidable or at least potentially preventable.
In 2024/2025, six harms made up the majority of cases in Canadian hospitals outside Quebec: electrolyte and fluid imbalances, urinary tract infections, delirium, pneumonia, “aspiration pneumonitis” (when things meant to be in the stomach go down the wrong tube into the lungs, causing inflammation) and post-surgery or post-procedural infections.
People harmed while in hospital stay, on average, five times longer than those who aren’t — nearly a full month, 28 days, versus six days for someone who isn’t harmed.
In addition to tying up critically needed beds, that longer length of stay costs more: an average hospitalization is just under $10,000. The cost of caring for someone who experiences harm is roughly $45,000, about four-and-a-half times more.
The data show there were 55,929 hospital-acquired infections in 2024-25, 6,769 “patient accidents,” 33,470 procedure-associated harms, like a puncture wound during surgery, and 86,817 medication-associated conditions.
Men were slightly more likely than women to experience harm, while the crude rate overall was slightly higher in urban versus rural or remote hospitals.
More than 21,600 people developed delirium, a sudden and serious state of confusion and disorganized thinking. It’s often age-related and the result of “one thing compounding another,” Flemons said, like being in unfamiliar surroundings and interrupted sleep.
While it’s a known risk factor for dementia and death, delirium often goes unrecognized. People with fractured hips and cardiac disease are at increased risk.
“But it doesn’t mean there isn’t anything we can do about it,” Flemons said. “You watch the drugs you give to people. You watch their fluid balance. You try to get them out of hospital as soon as possible. You try to get them up and mobile. Nice to say, hard to do, but you get them into rooms where they can sleep at night.”
Aspiration pneumonitis can be reduced by making sure people can swallow safely and properly, rather than just putting a tray in front of them and say, “Enjoy your dinner,” Flemons said.
Falls account for most patient accidents. “We also see fractures, or dislocations,” CIHI’s Davidson said. A frail patient might suffer a fracture or dislocated bone when moved. “It’s not necessarily that you got up and fell out of bed. But during the process of care there might be trauma to the body.”
CIHI doesn’t track deaths related to hospital harm. The study is based on a discharge abstract database. “When a patient is discharged home, we’re able to look back on their process of care,” Davidson said.
For patients, communication is essential, she said. “If a patient or a loved one is receiving care, asking questions about the care you’re about to receive, what it will feel like, what to expect, and to speak up if it doesn’t feel right, or if it’s not what they were told.”
Too much secrecy still shrouds hospital harm, others said.
Flemons is a co-author of a 2022 book on the lessons learned during a devastating drug mix-up that killed two Calgary patients, an elderly woman and middle-aged man who were in intensive care with kidney failure when they were given the wrong solution during dialysis. Both were given potassium chloride, which can stop the hearts in minutes, instead of sodium chloride.
At the time, the dialysis solution wasn’t commercially available. “So we were mixing it up in our own central pharmacy. And one fateful day, the pharmacy people mixed up the wrong solution,” Flemons said. An investigation found the fatal error was the result of “just a whole series of events that ultimately culminated in that tragedy,” he said.
“But we actually (publicly) spoke about it, and you don’t hear about that very much anymore.”
When errors aren’t talked about openly “that sends the wrong culture message, which is, we kind of know bad things are happening … (but) we don’t really appreciate, until a report like (CIHI’s) comes out, how cumulatively it affects so many people,” Flemons said.
Canada needs to go back 20 years, “to the concerted effort that happened after the Baker-Norton report,” he said. It’s one thing to have Canada-wide data, he said. “We need to get it down to province-wide, down to institutions and then get that into boardrooms, so that people are actually looking at it and asking some difficult but necessary questions, which is, ‘What is our strategy to change this locally?’”
National Post
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