Winnipeg Free Press - PRINT EDITION

Hospital mishandled drugs 72 times in 22 months

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St. Boniface Hospital staff left a powerful painkiller on a breakfast tray that was taken back to the kitchen, accidentally pocketed a vial of ketamine later recovered in a dryer lint trap at home and found seven doses of oxycodone in a syringe next to a patient's bed.

According to an access-to-information request, hospital staff mishandled narcotics 72 times in the nearly two years between January 2010 and October 2011.

The daily incident reports detail missing, stolen or contaminated drugs listed in the Controlled Drug and Substances Act. The reports suggest only small amounts of prescription narcotics went missing over the 22-month period.

The majority of reports concern pain drugs like morphine, fentanyl, which is an opiate more potent than morphine and typically administered by a patch, and Dilaudid, another type of opiate. Drugs like Tylenol 3 and methadone appear in the reports as well.

Most incidents involve small amounts, usually a dose for a single patient lost because a tablet was dropped or an IV bag leaked.

Others are accounted for by user or delivery errors caught by the Pyxis, a machine St. Boniface has used since 2000 to dispense drugs.

"This is where technology really helps in making sure the system has accountability," says Lori Motluck, executive director of clinical programs and chief nursing officer. "But with our system of reporting, still, we are trying to develop a culture of safety to make sure the medication goes to the patient in the right dose in the right way."

Access-to-information requests were sent to the city's two biggest hospitals last fall. St. Boniface Hospital, the city's second-largest, was the most transparent about its drug reports. An identical request about missing drugs was also sent to Health Sciences Centre but staff there responded with a summary of incidents that occurred between February and July of 2010.

HSC, the province's largest hospital, reported seven occurrences of missing drugs during that time.

With 453,059 drugs dispensed at St. B over 22 months, the hospital had a 0.016 per cent rate of reported errors. Motluck thinks St. Boniface is still under-reporting, though, and wants staff to learn from their mistakes to improve medication delivery.

Twenty reports indicate medication was dispensed, never administered and then improperly disposed of. More than half of these were pain drugs, generally only a single dose.

There are two instances of bulk amounts going missing. In July 2011, there was a discrepancy of 50 vials of Dilaudid, and in October 2011, 16 vials of sufentanyl were unaccounted for. Neither occurrence report suggests how the matters were resolved.

With the help of Free Press staff, students in Red River College's Creative Communications program learned how to mine freedom-of-information legislation for stories governments might not want told. To read all the stories, visit

Republished from the Winnipeg Free Press print edition January 10, 2012 A6

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