Transparency vital for confidence in health system, nurses union, Doctors Manitoba say
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Hey there, time traveller!
This article was published 08/03/2024 (940 days ago), so information in it may no longer be current.
After recent patient deaths in the emergency rooms at Grace and St. Boniface hospitals were ruled critical incidents, health officials promised “comprehensive” reviews in a bid to prevent similar fatalities.
The public could be kept in the dark, however, when it comes to the findings and proposed safeguards to protect patients and improve the taxpayer-funded health-care system.
Manitoba Health stopped publishing critical incident review recommendations on the provincial government’s website five years ago, and it’s unclear when the information will be made public again.
“I absolutely think that transparency is key. That’s how we learn and how we ensure that we don’t follow the same history,” said Darlene Jackson, president of the Manitoba Nurses Union, which has more than 12,000 members.
“That’s how we make change and that’s how we get better.”
JOHN WOODS / FREE PRESS FILES “I absolutely think that transparency is key,” said Darlene Jackson, president of the Manitoba Nurses Union.
A critical incident is described as an unintended event that results in death, injury or disability to a person using health services in a hospital, personal-care home or other setting.
Examples include falls, delays in treatment, incorrect surgeries and wrong doses of medication.
A government spokesman said Friday the province is developing “a modernized format” for recommendation reports — or patient-safety learning advisories, as they are officially known — and an “updated process” for online reporting.
A timeline was not given.
Failing to share the reports with the public could undermine Manitobans’ confidence in the system, said Jackson.
“The public really needs to know that that’s been done and what the outcome is,” she said. “How are we going to make this better? How are we not going to repeat our mistakes or history? I think that’s really important.”
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Doctors Manitoba, which represents more than 4,000 physicians and medical learners, also supports the release of recommendations, or lessons learned.
“Doctors Manitoba sees value in publishing annual reporting on patient-safety incident trends and posting alerts or learning summaries about any critical incident investigation that uncovers broader system issues which could be prevented,” a spokesperson wrote in an email.
“Posting summaries and trends like these helps to build public confidence that the health system is focused on providing them with safe care without disclosing private health information, undermining a culture of reporting critical incidents, or compromising the ability for investigators to get to the truth about what happened to help prevent future incidents from recurring.”
In an interview with the Free Press last month, Health Minister Uzoma Asagwara pledged “modernized” reporting.
“I am committed to making sure we are applying lessons that we learn,” said Asagwara.
RUTH BONNEVILLE / FREE PRESS FILES In an interview with the Free Press last month, Health Minister Uzoma Asagwara pledged “modernized” reporting.
The minister described a balancing act when it comes to sharing the information with the public. Patient or family privacy and dignity must be respected in public documents, Asagwara said.
Molly McCracken, director of the Canadian Centre for Policy Alternatives’ Manitoba office, said the reports serve as an “accountability mechanism.”
“Publicly reporting them is a key part of fixing the health-care system and informing Manitobans how the system is preventing particular critical incidents from occurring again in the future,” she said.
According to Manitoba Health, critical incidents are thoroughly reviewed, and all lessons learned are shared within the health-care system, and with the patients involved and/or their families.
In 2006, Manitoba became the second province to bring in legislation for mandatory no-blame critical incident reporting to develop a culture of learning and openness.
Around that time, research by the Manitoba Centre for Health Policy found the frequency of adverse events was quite low.
“Publicly reporting them is a key part of fixing the health-care system and informing Manitobans how the system is preventing particular critical incidents from occurring again in the future.”–Molly McCracken
Four years later, an NDP government produced the first detailed annual patient-safety report. It said quarterly summaries of critical incidents would be published online, starting in 2011.
Reporting has lagged at times since then, while the current availability of reports on the government’s website is inconsistent or incomplete.
The most recent annual report is from 2012, when the NDP was still in office. It is unclear why those reports were discontinued.
The website doesn’t list any quarterly reports published before April 2019, when the PCs had been in power for three years. Those reports contain only brief summaries of individual critical incidents.
January ER death ruled critical incident
The death of a patient in St. Boniface Hospital’s emergency department Jan. 19 has been ruled a critical incident, the Winnipeg Regional Health Authority confirmed to the Free Press this week.
The patient had been waiting about five hours, was triaged and had received various diagnostic tests, the WRHA said previously.
An initial patient-safety review determined the death met the criteria of a critical incident.
The death of a patient in St. Boniface Hospital’s emergency department Jan. 19 has been ruled a critical incident, the Winnipeg Regional Health Authority confirmed to the Free Press this week.
The patient had been waiting about five hours, was triaged and had received various diagnostic tests, the WRHA said previously.
An initial patient-safety review determined the death met the criteria of a critical incident.
“We once again offer our sincere condolences to the family of the patient,” a WRHA spokesperson wrote in an email. “A comprehensive review into the circumstances that led to the incident is now ongoing and no further details will be released publicly due to patient confidentiality.
“As part of the review, recommendations for improvement to the health-care system may be made to reduce risks to patients in the future, and results will be shared with family once complete.
“We are grateful for all health care staff who continue to step up every single day to provide safe, compassionate care to patients and families.”
Provincial legislation defines a critical incident as an unintended event that occurs when health services result in serious and undesired consequences which are not the result of an underlying health condition “or from a risk inherent in providing health services.”
The death of a patient in Grace Hospital’s emergency room Nov. 18 was also ruled a critical incident.
The WRHA previously confirmed the patient had been in the ER for 33 hours and was triaged, assessed and receiving care, while awaiting transfer to an in-patient bed.
The annual number of critical incidents reported to Manitoba Health has fluctuated. The province said 163 were reported in 2023.
A separate government webpage contains recommendation reports published between September 2014 and February 2019, a timeline that straddles a transition between NDP and Tory governments.
Each report provides a summary, key findings and proposed measures to improve care.
A report from February 2019 describes how a patient was found dead with a lap belt around their neck, after partially sliding down out of a specialized wheelchair.
A review found the belt was secured by staff at a higher level than it is designed for. The report identified gaps in training provided to staff and regional policy.
Public documents do not contain locations or personal information to avoid identifying patients and staff.
Media coverage of a critical incident occasionally forces a health authority to divulge findings and recommendations. Last year, Shared Health made public the findings and three recommendations, following the death of a patient in Health Sciences Centre’s adult emergency department.
The Winnipeg Regional Health Authority includes some critical incident data in its annual reports.
Interest in patient safety increased after the discovery in 1994 of 12 potentially preventable infant deaths in the pediatric cardiac program at HSC, according to Manitoba Health.
An inquest report in 2000 led to the creation of a steering committee overseen by University of Manitoba Prof. Paul Thomas. All 53 of its recommendations to improve patient safety were implemented, including a system to learn from medical errors.
“I was really disappointed and discouraged to learn it’s been five years since these reports were released.”–Prof. Paul Thomas
Thomas said the public should be informed of lessons learned from critical incidents.
“I was really disappointed and discouraged to learn it’s been five years since these reports were released,” said Thomas, who was the first chair of the Manitoba Institute for Patient Safety, which formed in 2004 and was later absorbed by Shared Health.
Asagwara couldn’t speak to the previous governments’ decisions or rationale, while responding to a question about why some information is no longer being made public. The minister accused the Tories of prioritizing cuts.
The PC party did not provide an explanation as to why recommendations stopped being released under its watch.
Policies and practices vary by province. Saskatchewan, the first province to mandate critical incident reporting, includes a summary of critical incidents in its health ministry’s annual reports.
Spokesman Dale Hunter said a patient-safety alert, which contains recommendations following a critical incident, is issued when it may benefit that province “more broadly.” The most recent alert on the Saskatchewan government’s website was published in September 2019.
chris.kitching@freepress.mb.ca
Chris Kitching is a general assignment reporter at the Free Press. He began his newspaper career in 2001, with stops in Winnipeg, Toronto and London, England, along the way. After returning to Winnipeg, he joined the Free Press in 2021, and now covers a little bit of everything for the newspaper. Read more about Chris.
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