Child death, instrument left in patient detailed in critical incident report

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This article was published 24/04/2022 (1549 days ago), so information in it may no longer be current.

Three patients with stroke symptoms didn’t get timely enough care when seeking treatment, a new report detailing critical incidents reported to Manitoba Health suggests.

The report also details an incident in which a child died after “entrapment” involving a hospital bed and another in which a surgical instrument was left inside a person undergoing surgery.

The report on Critical Incidents Reported to Manitoba Health includes a total of 48 incidents documented over a three-month period in 2020, from July 1 to Sept. 30. Critical incidents “reflect serious and unintended harm experienced by individuals using Manitoba’s health care services,” according to the province’s website.

One-quarter of the incidents listed in the new report resulted in death.

The report lists the “degree of injury” (major or death) and a brief description of the incident. It does not list when or where they occurred, demographic information about the patients, nor if anyone was disciplined or if any organization faced repercussions as a result of the incidents.

The stroke incidents include two cases where patients arrived in emergency rooms with stroke symptoms.

“Stroke protocol not implemented,” the report states. Neither patient died but remained in “care.”

The third stroke incident involved a patient who was transferred to an emergency room where they were assessed for stroke-like symptoms.

“Assessment determined client had experienced a stroke and onset of symptoms exceeded time frame for treatment for reversal of stroke,” the report states. That patient remained in hospital.

The child case involved “bed entrapment in community.”

“A hospital bed with full side rails supplied through the Home Care Program for a child with an underlying health condition contributed to an event of bed entrapment and loss of life,” is all the report states.

The incident involving the missing surgical device reads: “During surgery, part of a surgical instrument was noted to be missing. X-ray revealed foreign body remained in the patient. Attempts to retrieve the foreign body were unsuccessful. The surgical site was closed with the foreign body retained.” The person did not die, according to the report.

No one from the province was available for comment Saturday. Typically, the province does not comment on cases detailed in the report.

The province’s website says clinical experts “thoroughly review each incident and make recommendations about how the system can improve in order to avoid harm to others.” The postings are delayed — the new report is focused on incidents from nearly two years ago — “to allow this process to occur.”

katrina.clarke@freepress.mb.ca