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This article was published 22/1/2019 (214 days ago), so information in it may no longer be current.
The wrong patient was operated on after the diagnostic imaging for another patient was mistakenly put in the other's computerized chart.
And a patient died after a medication line was wrongly inserted into an artery instead of their jugular vein.
These are just two of 33 incidents reported in the province's latest critical incident report which covers the period between Jan. 1, 2018 and March 31, 2018.
During that period, five patients died in hospitals, one in a personal care home and another in a group home.
The report also lists what happened to 26 other Manitobans, who were in hospitals, personal care homes or group homes, and suffered major injuries with many resulting to life-altering injuries or excruciating pain.
In the incident with the wrong patient receiving surgery, doctors didn't know the person had undergone unnecessary surgery until nine days later when the reporting error was found and the report amended.
The province releases no further details on any incident so it isn't known what happened to the patient who received the wrong surgery, the patient who didn't receive the surgery, or what surgery was performed.
A provincial spokeswoman said that's because the incident reports, which come out four times a year, were designed by the province not to assess blame against anyone in the medical or caregiving fields.
"It is not about blaming it is the learning," she said on Tuesday.
"It is about finding out what went wrong so we can fix it so it won't happen again."
The spokeswoman said the process does not stop other disciplinary investigations or complaints to professional regulatory bodies or civil lawsuits.
In the incident involving the placement of the medication line in the wrong place, doctors didn't realize the mistake until the next day. After the line was removed, the patient was no longer fully conscious and a later CT scan found the patient had suffered a stroke during the initial procedure.
In another ultimately fatal incident, a man came to an emergency department via ambulance with a history of chest pain and taking methamphetamine. The patient left an hour later with nothing in the hospital's reports showing assessment or treatment of the chest pain.
An hour later the man was found dead in the community.
In yet another incident, a resident of a personal care home told staff three times he was experiencing chest pain and his care plan indicated he would want medical treatment. There were no documents showing any nursing assessment of him and 12 hours later he stopped breathing and a Code Blue was initiated, but he died.
Other major incidents, which did not result in death, include a person with cognitive delay, who is incontinent and needs caregivers to move them around in bed so they don't get bed sores. That person's family only discovered after they had been discharged they now had a Stage 4 pressure injury that wasn't there before being admitted to hospital. An investigation found there had been no care plan for skin breakdown management set up even though the patient was deemed at high risk for pressure injury.
According to the U.S.-based National Pressure Ulcer Advisory Panel, a Stage 4 pressure injury can be a bedsore so deep you can see straight to a person's bones.
In another case, a child came to the emergency room of Children's Hospital suffering an overdose of Tylenol, Xanax, and alcohol. After getting the results of bloodwork, showing a toxic level of Tylenol and elevated liver functions, the doctor wrote in the patient's chart the child was "medically clear" and admitted them into the inpatient mental health unit.
Three days later, when bloodwork showed the child's Tylenol level had increased, they were rushed to the emergency department to be treated for Tylenol overdose for the next two days. The report stated the treatment delay resulted in the child spending more time in hospital.
Kevin Rollason is one of the more versatile reporters at the Winnipeg Free Press. Whether it is covering city hall, the law courts, or general reporting, Rollason can be counted on to not only answer the 5 Ws — Who, What, When, Where and Why — but to do it in an interesting and accessible way for readers.