Dear Colleagues,
There have been a number of media stories this week on a multi-drug resistant bacterial outbreak of pseudomonas that occurred at Toronto General Hospital's MSICU between 2004 and 2006 which contributed to or directly caused the tragic death of 12 patients. While harmless to most healthy people, this bug can lead to wound or bloodstream infections or pneumonia in seriously ill patients. After extensive analysis, we determined that the hand hygiene sink drains was the primary source of the outbreak. Because of the shallow sink bowl design, when water went down the drain it would splash pseudomonas and contaminate sterile dressings and other surfaces. The study, authored by Dr. Michael Gardam, Dr. Camille Lemieux, Dr. Susy Hota and Karen Stockton from UHN's Infection Prevention and Control appears in the January issue of Infection Control and Hospital Epidemiology. 

Today's Globe and Mail editorial recognizes our openness in talking about this 2006 outbreak so that other hospitals and health organizations can benefit from our experience. I'm very proud of our just culture and commitment to transparency and this is just one more example. If you have a moment, please read the Globe editorial.

​Setting an example, Globe and Mail
December 17, 2008 
One might expect that a hospital that inadvertently kills 17 patients in three months because of faulty hand-washing stations would not be eager to talk about it. But the Toronto General Hospital not only talked about its fatal mistake; its doctors published an article about it in a medical journal. This willingness to admit to errors and try to learn from them, and help others to learn from them, stands in brave contrast to much of Canada's medical culture of silence.

​​The bug Pseudomonas aeruginosa loves the moisture in drains, and while it's no threat to healthy people, it can kill those with weak immune systems. When a drug-resistant form of the bug struck Toronto General transplant patients between December, 2004 and March, 2006, the hospital's investigation led to the gooseneck spouts that splashed water out of the drains and on to patients' beds. “People need to know this,” says Michael Gardam, senior author of the article published in the January edition of Infection Control and Hospital Epidemiology. Indeed they do. But it is all too rare for Canadian medicine to respond to that need.

Deny, obfuscate, cover up. That's what some major players in Canadian medicine did for years when the possibility of catastrophic errors was brought to their attention. Not one but three separate judicial inquiries have been held in the past year into such cover-ups. From 1991 to 2004, the Office of the Chief Coroner of Ontario allowed a scientist in charge of figuring out how small children die to run wild. The result was that 20 people were wrongly convicted of or wrongly charged in murders or other serious crimes. There was an inquiry into Eastern Health, the biggest government health authority in Newfoundland and Labrador, which botched nearly 400 cancer tests between 1997 and 2005. And there was an inquiry into the Miramichi Regional Hospital in New Brunswick, where the head pathologist from 1994 to 2007 misread countless tests. In all these cases, people needed to know, but the authorities sat on the truth. 

If Canada is to make progress in reducing the hospital-borne infections that kill an estimated 8,000 people a year, it needs to put defensiveness, individual egos and bureaucratic self-interest aside and speak openly and self-critically. Toronto General Hospital did that, and in a better world would not be deserving of praise. When people need to know, Canadian medicine should follow the Toronto General's example, and speak up.​
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