Critical incident reports should be public

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This article was published 13/03/2024 (589 days ago), so information in it may no longer be current.

When medical errors occur that result in serious harm to patients, the public has a right to know about them.

There are multiple reasons for that, not the least of which is to ensure accountability in the health-care system and to publicly document the steps taken to prevent similar events in the future.

Critical incidents, as they are known in the medical community, occur when an unintended event results in death, injury or disability to a person using health services in a hospital, personal-care home or other settings. They are investigated using a “no blame” approach to encourage front-line health care workers to share as much knowledge as possible without fear of reprisal. The objective is to uncover what went wrong and to implement safeguards to prevent similar errors in the future.

Publishing the details of those incidents and the steps taken to respond to them, is, well, a critical component of the process. Without that public accountability, it is easier for medical errors to fall under the radar and for the urgency around preventing them in the future to be weakened.

Until five years ago, critical incident review recommendations were reported publicly on the Manitoba Health website. For reasons that remain unclear, government stopped publishing them in 2019. There was no compelling reason to do so. In fact, it was a step backwards in the evolution of critical incident reporting.

A spokesperson for the NDP government told the Free Press last week that the province is developing a “modernized format” for releasing recommendation reports. However, no timeline was given as to when those reports might be made public again.

The decision to stop publishing critical incident review recommendations in 2019 occurred under the previous Progressive Conservative government. The current government cannot be blamed for that. However, it has an obligation to fix the mistake.

No one from the PC caucus, when asked by the Free Press, provided an explanation as to why the province stopped publishing the reports.

The unfortunate outcome: there is now less public accountability around critical incidents than there was five years ago.

Health Minister Uzoma Asagwara said last month the NDP government is committed to releasing the reports through a new “modernized” system. However, the minister also did not say when publication would resume.

This should be a priority for government. There was no valid reason to stop publishing the reports in the first place.

Appropriate steps were taken to protect the identities of patients and medical practitioners and to comply with the province’s Personal Health Information Act. Those considerations were paramount from the very beginning of the process, since it was never about assigning blame and always about mitigating future harm.

If minor changes to the reporting process were required, those could have been achieved while still publishing the reports.

There is a famous maxim from a court decision by British Chief Justice Lord Gordon Hewart in 1924 that is still regularly quoted in Canadian court verdicts: “(it) is of fundamental importance that justice should not only be done, but should manifestly and undoubtedly be seen to be done.” The same holds true for critical incident reviews.

Manitoba Health has not provided a valid reason for discontinuing publication of critical incident review recommendations. Absent that justification, government should resume releasing them immediately.

The reports already exist and are circulated within the healthcare system. There is no reason why they cannot be posted online again.

Publishing critical incidence review recommendations is one of the most important aspects of maintaining openness and transparency in the public heath-care system. This deserves the immediate attention of government.