One of the first solid studies to look at medical errors in Canadian health care found nearly a quarter of patients had adverse events following discharge from hospital - and half of those problems were either preventable or ameliorable.

While the bulk of the adverse events caused only symptoms or transitory problems, a small portion - three per cent each - led to permanent disability or death, the researchers found.

The findings highlight the need for better post-discharge surveillance of patients, said the study's authors, from the Ottawa Health Research Institute, the University of Ottawa medical school and the Institute of Clinical Evaluative Sciences in Toronto.

"Monitoring was judged to have been inadequate for each patient with an ameliorable AE (adverse event) and a substantial portion of those with preventable ones," they wrote in the article, published Tuesday in the Canadian Medical Association Journal.

Lead author on the study was Dr. Alan Forster, an internal medicine specialist who was involved in a similar study at Brigham and Women's Hospital in Boston several years ago.

The Canadian work was praised in the journal by the authors of the first ever national report on adverse events, expected to be published next month.

Ross Baker and Dr. Peter Norton, experts in the field of patient safety, noted in a commentary that the study is one of the first anywhere to look at adverse events that occur after discharge.

"This transition is clearly a critical event," said Baker, who teaches in the department of health policy, management and evaluation at the University of Toronto.

"We know that patients are leaving the hospital sooner. We know that they're often sicker and less able to look after themselves. And what Dr. Forster's pointing to is that sometimes that means that things happen that shouldn't happen after they leave the hospital," Baker said in an interview.

The study was done at Ottawa Hospital, where the researchers traced the experience of 328 patients discharged from the general internal medical service over a 14 week period in 2002. Participants were interviewed by phone and their charts were reviewed.

Twenty-three per cent had at least one adverse event, the term now used to describe what once were called medical errors. Examples of adverse events included being prescribed a drug that is unsafe to take with previously prescribed medication - or the wrong medication - or developing a pressure ulcer.

An example of a preventable adverse event found by the researchers was the fact that someone on blood-thinners wasn't adequately followed up and went on to suffer a stroke. Ameliorable adverse events found were often drug reactions.

Nearly three-quarters of the adverse events were caused by drug interactions. Sixteen per cent were caused by therapeutic errors and 11 per cent were infections patients picked up while in hospital.

The Canadian results closely mirrored those of the U.S. study - a fact that underscores the need for better management of the transition from hospital to home, Baker said.

"What that suggests is that this isn't simply a question of the deficiencies of the Canadian health-care system. This is a question of the need to become more sophisticated and more resilient in the communications strategies between hospital-based care and care in the community."

Forster said he was somewhat surprised at the Canadian figures, admitting he had feared they might be higher than the U.S. numbers because the population of patients followed in his study was considerably older than those in the American study.

The average age in the Canadian study was 71 years, compared to 57 years in the earlier U.S. research.

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