Critical-incident numbers improve, but problems remain: health unions

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This article was published 05/11/2024 (336 days ago), so information in it may no longer be current.

The number of critical incidents in Manitoba health-care facilities fell by nearly 50 per cent in the three months ending March 31, but glaring gaps in the system and a lack of transparency are continuing problems, union leaders say.

Manitoba Health’s latest available report lists 30 critical incidents, including nine deaths, between Jan. 1 and March 31. The report shows patients experienced delays and missed opportunities in receiving care.

By comparison, the department listed 54 incidents, including 20 deaths, between Oct. 1 and Dec. 31, 2023 — the highest number of incidents recorded since late 2020 when health-care facilities were battling COVID-19.

The reported decrease surprised Manitoba Nurses Union president Darlene Jackson, given the ongoing staffing crisis in the health-care system.

“Critical incidents are directly connected to the ability to have oversight on your patients, which is a direct result of understaffing,” Jackson said Monday.

In 2023, there were 166 critical incidents, including 42 deaths, up from 130 incidents (31 deaths) in 2022, based on previous public reports. Totals were higher in 2021 (181 incidents, 73 deaths) and 2020 (180 incidents, 64 deaths).

Jackson said health-care staff are stretched too thin and have less time to spend with patients, leading to opportunities for critical incidents to occur.

Manitoba Association for Health Care Professionals president Jason Linklater echoed Jackson’s concerns, adding the reports don’t go far enough to capture the details of the incidents so they can be prevented in the future.

Of the nine deaths in the first quarter of 2024, four patients died due to the result of a delay in the recognition, response or treatment of an “acute medical condition.”

“I could think of a hundred things that could fall under those categories. We need to be more specific so we can prevent these incidents from happening in the future. One critical incident is one too many,” Linklater said.

The most recent report shows four patients experienced a change or deterioration in their condition with a delayed or no response from health-care workers, which resulted in their deaths.

One patient fell, got trapped in a bed rail and died as a result, according to the report.

Of the 21 major incidents reported, 12 related to delays in recognition, intervention or diagnosis of acute conditions.

The reports must be more transparent, Linklater said.

Last week, Shared Health launched a web page dedicated to patient-safety learning advisories. The notices offer a look into some critical incidents and contain recommendations for health-care workers to prevent similar scenarios in the future.

Manitoba Health stopped publishing its advisories on the provincial government’s website five years ago and the new page is meant to replace the former Progressive Conservative government’s format.

A Shared Health spokesperson said the advisories are designed to capture “systemic learnings” and may be based on multiple events or critical incidents that occur over a period of time. Not all critical incidents result in a Shared Health advisory.

Dates and identifying information from the critical incidents are withheld to protect patient safety, the spokesperson said.

The latest learning advisory lists a delay in performing an angiogram, a scan that shows blood flow through arteries, veins or through the heart when a patient is experiencing chest pains.

The bulletin details the investigation into the incident and that it was deemed critical because the patient received delayed care due to a gap in understanding about when the angiogram office could accept referrals, since it is not open 24-7.

The notice recommends Manitoba Health develop a memo to alert all physicians and nursing and unit-clerk staff about the hours of operation of the cardiac angiogram intake office.

The advisory notes the patient did, eventually, have the procedure.

Health Minister Uzoma Asagwara said the incident reports and Shared Health advisories are key in understanding and ensuring the critical situations don’t reoccur, and said the province will continue to disclose them.

Asagwara agreed that staffing the system will help, overall.

“Because when you do that, you reduce the pressures on the front-line health-care workers,” the minister said.

Jackson expressed concern that the looming respiratory virus season will put additional pressure on health-care staff and increase the risk of critical incidents.

“We have a finite number of nurses to handle flexes in the health-care system and we need to know there’s more being hired to handle this incoming season,” she said.

Since the NDP government tabled the budget in April, the province has hired 873 net new health-care workers, including 304 nurses, Asagwara said.

nicole.buffie@freepress.mb.ca