Winnipeg Free Press - PRINT EDITION

Hospital mishandled drugs 72 times in 22 months

  • Print

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.

crystal_laderas@hotmail.com garth.hilderman@gmail.com

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 winnipegfreepress.com

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

Fact Check

Fact Check

Have you found an error, or know of something we’ve missed in one of our stories?
Please use the form below and let us know.

* Required
  • Please post the headline of the story or the title of the video with the error.

  • Please post exactly what was wrong with the story.

  • Please indicate your source for the correct information.

  • Yes

    No

  • This will only be used to contact you if we have a question about your submission, it will not be used to identify you or be published.

  • Cancel

Having problems with the form?

Contact Us Directly
  • Print

You can comment on most stories on winnipegfreepress.com. You can also agree or disagree with other comments. All you need to do is be a Winnipeg Free Press print or e-edition subscriber to join the conversation and give your feedback.

You can comment on most stories on winnipegfreepress.com. You can also agree or disagree with other comments. All you need to do is be a Winnipeg Free Press print or e-edition subscriber to join the conversation and give your feedback.

Have Your Say

New to commenting? Check out our Frequently Asked Questions.

Have Your Say

Comments are open to Winnipeg Free Press print or e-edition subscribers only. why?

Have Your Say

Comments are open to Winnipeg Free Press Subscribers only. why?

The Winnipeg Free Press does not necessarily endorse any of the views posted. By submitting your comment, you agree to our Terms and Conditions. These terms were revised effective April 16, 2010.

letters

Make text: Larger | Smaller

LATEST VIDEO

Museum will create a conversation: Stuart Murray

View more like this

Photo Store Gallery

  • A young gosling prepares to eat dandelions on King Edward St Thursday morning-See Bryksa 30 Day goose challenge- Day 17- bonus - May 24, 2012   (JOE BRYKSA / WINNIPEG FREE PRESS)
  • A red squirrel peaks out of the shade in a tree in East Fort Garry, Sunday, September 9, 2012. (TREVOR HAGAN/WINNIPEG FREE PRESS)

View More Gallery Photos

Poll

Do you plan on attending any of the CMHR opening weekend events? (select all that apply)

View Results

View Related Story

Ads by Google