Review process impacts critical incident numbers: WRHA official

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This article was published 24/07/2018 (2724 days ago), so information in it may no longer be current.

Manitoba’s health system is recording only a fraction of the number of patient critical incidents it did five years ago, but it’s not because staff have become hesitant to report troubling events, a local official says.

Five years ago, Manitoba Health consistently reported more than 100 critical incidents every quarter. More recently, that number has fallen to the point where only 17 critical incidents were logged in the first three months of 2017, the latest information available.

Kerstin Jordan, director of patient safety with the Winnipeg Regional Health Authority, said health staff are still reporting as many patient events — or more — and the criteria on what constitutes a critical incident hasn’t changed.

But she said the review process has “evolved” in the past few years, and review teams are showing greater “diligence” in assuring events are more appropriately classified.

“I would say the analysis has changed, not the level of reporting,” Jordan said in an interview Tuesday.

A significant contributor to the high critical incident totals in the past was the large number of serious injuries due to falls, particularly in personal care homes.

Manitoba Health informed the WRHA in 2014 it was over-reporting patient falls as critical incidents. A 2010 provincial guideline outlines five factors in deciding whether a patient fall causing a fracture or other serious injury constitutes a critical incident.

The WRHA said it had been “erring on the side of being overcautious” in reporting such incidents in the past.

Government bureaucrats had planned to reduce the frequency of publishing critical incident reports on the Manitoba Health website to twice a year from quarterly because of the declining numbers. However, Health Minister Kelvin Goertzen quashed that idea Monday, after the Free Press raised the matter. The province also promised to publish updated numbers next month.

The thumbnail accounts contained in the critical incident reports are cryptic and often disturbing.

This is an example from the latest report: “A 20-month-old child was transported via ambulance to larger hospital in rural region. On arrival, the child remained in the arms of the mother for four hours without a nursing assessment being completed. The child was then found to be in critical condition. Both mother and child transferred to a tertiary care centre. Child found to have sepsis and possible bowel obstruction.”

Jordan said health workers are “absolutely encouraged” to report patient safety events. They can do so anonymously, she added.

Patients or their families can also use a special phone line to report patient safety concerns.

Teams consisting of patient safety consultants and clinical experts review the reported events. If the event is not deemed serious enough as to be classified as a critical incident, that isn’t necessarily the end of it, Jordan said.

“If something is not a critical incident, it doesn’t mean that it’s not reviewed and there isn’t learning over it,” she said.

In 2006, the province introduced no-blame critical incident reporting across the health system to nurture a culture of openness and learning about such incidents. It’s believed only a fraction of critical incidents are, in fact, reported.

Jordan emphasized declining critical incident numbers are not due to a lack of reporting of events by staff.

“I am confident that there is good reporting… I’m confident that we are doing our very best to encourage staff to report patient safety events. And I am confident in the team that is looking at these events and the tremendous amount of work that goes into making these decisions about… how they are categorized.”

larry.kusch@freepress.mb.ca