Death and unintended harm: critical incident report highlights health system concerns By: Chris Kitching Posted: 6:20 PM CST Friday, Jan. 12, 2024

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This article was published 12/01/2024 (1003 days ago), so information in it may no longer be current.

The death of a Manitoba emergency room patient and a minimally invasive procedure carried out on the wrong person are among 41 critical incidents listed in the government’s latest quarterly report.

Published Friday, the public report cites 10 deaths and other incidents that resulted in “serious and unintended” harm to people using health-care services between Oct. 1 and Dec. 31, 2022.

The document, which is short on details, identifies multiple incidents in which patients experienced delays in diagnosis and treatment or where opportunities for earlier intervention were not recognized or realized.

Critical incident report

 

After reviewing the report, Manitoba Nurses Union president Darlene Jackson said chronic staff shortages likely factored into incidents, as there are not enough eyes to monitor patients.

“I think critical incidents are fairly rare. This is not an everyday occurrence,” she said. “However, I will say they are preventable.”

It is crucial steps are taken to prevent incidents from happening again, said Jackson.

The December 2022 death of Fred Douglas Lodge resident Jennie Sankow, 90, was deemed a critical incident. She died from influenza A after the Winnipeg personal care home failed to vaccinate her against the virus, her family said.

Sankow’s daughters, Jennie Malloy and Catherine Keating, don’t know which incident in the report is their mother’s death, because the descriptions are vague.

“If you didn’t know the terminology, you would be lost,” said Keating. “It’s not made easy for you.”

Malloy noted the report doesn’t say if any measures were taken to prevent similar deaths or injuries.

She said those are lost opportunities to inform the public about improvements and allow people to educate themselves about what to be concerned about in the health-care system.

“What’s the purpose of putting this out? You don’t know anything about what was done in the background to correct these issues,” she said. “The community deserves to know what they did to… prevent these incidents from happening again.”

In one case, a patient died from receiving an antidote treatment above the maximum dosage for a suspected overdose, the report said.

Another death involved a patient who was under observation in an ER. Their condition deteriorated and there was a delay in care.

A review of a third death found gaps in monitoring “may have led to delayed recognition and response to clinical deterioration” of a patient who had an acute medical condition.

Of the non-fatal incidents, a minimally invasive procedure was carried out on the wrong patient, who then had to undergo diagnostic testing to rule out harm.

A patient was released from an ER and later found unresponsive in the same facility.

One person was admitted to hospital after being given an unintended medication, while another underwent prolonged treatment and recovery after a fracture was not discovered on an X-ray.

“The government releases them, but it feels like they’re doing minimal duty to release them.”–Prof. Neil McArthur

Manitoba Health typically publishes a list of critical incidents, formally known as patient safety reports, on a quarterly basis.

There were some gaps in the schedule in the past, noted Prof. Neil McArthur, director of the University of Manitoba’s Centre for Professional and Applied Ethics.

“The government releases them, but it feels like they’re doing minimal duty to release them,” he said.

The reports provide brief descriptions — usually one or two sentences — of a death or “major” circumstances that were declared critical incidents.

For confidentiality purposes, the reports do not contain names, specific medical conditions, dates, locations or other information that could identify the patients or staff involved.

According to the province, clinical experts thoroughly review each incident and make recommendations in a bid to improve the system and avoid harm to others.

The public posting of an incident is intentionally delayed, usually by about 12 months, to allow that process to unfold.

“The community deserves to know what they did to… prevent these incidents from happening again.”–Jennie Malloy

The reports do not mention the findings of any reviews or recommendations, nor whether recommendations were or are being implemented or if any other action is being taken.

Manitoba Health has a webpage for recommendation reports conducted in the wake of critical incidents, but none have been published publicly since 2019.

Posting recommendations is a crucial step to show the public follow-ups have taken place, said McArthur.

Health Minister Uzoma Asagwara was not made available for an interview Friday.

On Jan. 4, Asagwara told the Free Press the NDP government, elected in October, will publish critical incident reports consistently.

It is looking into ways to modernize the public release of health-care data, the minister added. Specifics were not released.

Quarterly critical incident reports do not assign blame. Mandatory no-blame critical incident reporting was introduced in 2006.

A spokesperson pointed to the government’s website, which states: “The purpose of reporting is to look at what can be done differently and what improvements can be made to the way health care providers work.”

The website said the process doesn’t replace other disciplinary investigations, such as employer reviews, complaints to professional regulatory bodies or civil lawsuits.

chris.kitching@freepress.mb.ca