Drop in critical-incident deaths, major injuries in Manitoba’s health-care system

Gaps, delays or missed opportunities factored into a majority of 36 critical incidents reported by Manitoba’s health system in the final quarter of 2024 amid a year-over-year decrease.

The annual number of critical-incident deaths and major injuries in hospitals, personal-care homes and other health-care settings dropped by 24 per cent and 18 per cent, respectively, from 2023 to 2024, based on government data.

“One incident is an incident too many. It’s important that for every incident that is reported, we learn from them, that we take steps to address them and implement measures to prevent those incidents from occurring in the future,” Health Minister Uzoma Asagwara said. “While it’s a positive to see those numbers decrease, we know there’s more work to do.”

Eight deaths and 28 major injuries between Oct. 1 and Dec. 31, 2024 were deemed critical incidents.

The province reported 32 deaths and 102 major injuries in 2024, down from 42 deaths and 124 major injuries in 2023.

“I’m happy to see the numbers have decreased a bit, but as far as I’m concerned one major incident or a death is one too many,” Manitoba Nurses Union president Darlene Jackson said. “I would like to see that trend go down even further.”

In 2024’s final quarter, one patient died after a delay in diagnosis and treatment of an acute medical condition. A patient with acute needs died amid a delay in transfer to a higher level of care. A third death occurred after gaps in monitoring and assessment.

Of the major injuries, the report said an infant was born with an infection after “opportunities for earlier treatment were not recognized.”

A “foreign” item was left inside a patient after a surgical procedure, resulting in an infection.

Four patients or residents suffered skin tissue breakdowns. Two experienced “elevated drug levels.” One person suffered serious burns.

Provincial legislation defines a critical incident as an unintended event that occurs when health services provided to a person result in “serious and undesired” consequences, and does not result from the person’s underlying health condition or “from a risk inherent in providing the health services.”

Reviews take place in a bid to prevent similar incidents.

Quarterly reports provide brief descriptions of incidents. They do not disclose details that could identify patients, staff or locations.

Asagwara believes the government’s hiring of nearly 3,400 net new health-care workers, including about 1,100 nurses, since October 2023 contributed to some of the decrease.

Thousands more health-care workers are needed, they said.

Asagwara said information sharing has improved to ensure health-care staff learn lessons from critical incidents.

Jackson said descriptions of some incidents point to staff shortages and an inability to monitor patients.

“If you don’t have time to be turning your patient, doing skin care and repositioning to prevent pressure sores, you aren’t able to pick up on trends, if your patient is deteriorating,” she said.

Jason Linklater, president of the Manitoba Association of Health Care Professionals, said vacancy rates are between 20-50 per cent in key areas, including diagnostics, paramedics and the patient transport team.

“While it’s good to see some improvement after critical incidents spiked in 2023, the goal of every health-care professional is zero preventable negative patient outcomes,” he said in a statement.

“Unfortunately, Manitoba health care remains chronically understaffed, and until that changes we will continue seeing gaps and delays in care that can lead to critical incidents like these.”

Mandated minimum nurse-to-patient ratios would help to prevent critical incidents, Jackson said.

A committee with representatives from the provincial government, employers and MNU is working on proposed ratios.

Asagwara said recommendations, due by Jan. 1, will help guide how ratios are developed and rolled out.

“Our government is going to be taking steps to move this work as quickly as possible,” Asagwara said.

B.C. became the first province to establish mandated ratios when a phased rollout began in January. The minimum on general medical/surgical inpatient units is one nurse to four patients. The minimum for intensive care units is 1:1.

In a May policy brief, the Center for Health Outcomes and Policy Research at the University of Pennsylvania’s school of nursing advocated for mandated ratios in response to unsafe workloads and chronic understaffing.

The brief said ratio reforms that began in the Australian state of Queensland in 2016 led to 145 fewer deaths, 255 fewer readmissions and US$70 million in cost savings in the first two years.

California’s law, implemented in 2004, led to better nurse retention, less burnout and improvements to patient outcomes, the brief said.

chris.kitching@freepress.mb.ca