Cancer care mistakes, including surgery on wrong patient, detailed in Manitoba critical incident reports

A Manitoba breast cancer patient went under the knife for a lumpectomy in late 2017. Only later did doctors realize they'd operated on the wrong person.

That was one of 43 mistakes within Manitoba's health-care system detailed in a batch of critical incident reports, covering the Oct. 1 to Dec. 31, 2017 period, newly released by Manitoba Health.

This appears to be the only period in recent years where cancer records have been mixed up — and it happened more than once in the final months of 2017.

In the case of the mistaken lumpectomy, the critical incident report said diagnostic tests for two different patients were mixed up.

The person who had the lumpectomy never had cancer. The other patient, who was told they were cancer-free, actually had a breast tumour.

In an entirely separate case, a patient was told they did not have cancer. That, too, was a mistake — the breast tissue samples were mixed up, and the diagnosis was wrong. Treatment was delayed for the patient in that case and the "standard of care [was] not met," the incident report said.

In a third situation, a patient was treated for the wrong type of cancer. That was because the oncologist was given an old pathology report.

CBC News searched through every one of Manitoba Health's incident reports available online, dating back nearly eight years.

The previous reports detail occasional delays in cancer tests and treatment which resulted in "major" degrees of injury— but nowhere in eight years of reports was there an indication that cancer records were mixed up.

Increasing pressure in cancer care: nurses union

There could be more incidents that aren't being reported, says a Manitoba advocate for patients.

"We know that it's likely that not all critical incidents are reported for a variety of reasons," said Laurie Thompson, executive director with the Manitoba Institute for Patient Safety.

"Of course [these reports] concern me because there's people behind them. There's patients, there's families, there's staff — and they're tragic." 

Thompson said it's important to be clear, though, that the vast majority of times, medical care goes as planned.

But those who work in cancer care are feeling increasing pressure, according to the Manitoba Nurses Union.

"We are hearing that cancer care is getting busier," said Darlene Jackson, the union's president.

"The nurses are saying their workload is increasing, and they are tending to work more hours. Nurses are working flat out," she said.

"They are providing excellent care to their patients, but they're stretched thin. They're providing care to an increasing number of patients. And they're telling me they feel like the resources to support them aren't there."

Multiple checks needed: ER doctor

Cancer treatment is very complex, especially when multiple people are making judgment calls, says one Winnipeg doctor.

"Any time there is transmission of information for one person or another, or some judgment required … there's always the potential that a fax gets sent to the wrong person, a name gets switched or confused, [or] a number is written down incorrectly," said emergency room physician Merril Pauls.

"It seems hard to believe that something as simple as that could lead to that kind of a terrible outcome. That's why we want to think about how we can make multiple systems or multiple checks," he said.

Pauls said incident reports are an important way to identify holes in the health-care system.

These reports are the "tip of the iceberg," he said, so it's hard to know if an uptick in one type of medical mistake is because it's happening more, or simply because it's being reported more.

"[We want to make it] easier for people to report and discuss these events," he said.

CancerCare Manitoba — the provincially mandated agency in charge of cancer care — declined CBC's request for an interview.

In a statement, the organization wrote, "CancerCare Manitoba works with all of its partners in looking at the system more broadly, [to] consider what may contribute to incidents when they happen and look at how to make changes to prevent their recurrence."

Health Minister Cameron Friesen was not made available for an interview with CBC.

Other incidents detail holes in medical system

The Manitoba Health critical incident reports outline a number of other troubling incidents — some of which ended in patient deaths.

A baby born prematurely at a rural hospital was discharged and five days later, started to feed less. The infant was brought back to a local nursing station, but eventually died.

In another case, a mother went into labour and was given an epidural. Later, blood tests showed she had developed an infection. But the new mother was not treated for streptococcal infection and meningitis, and died.

In another incident, a patient with respiratory and heart failure being transported by air ambulance helicopter during a storm didn't receive oxygen because of a "loss of oxygen supply" — the reason for which wasn't explained in the report. The person went into cardiac arrest and died after being removed from life support days later.

In another case, a patient with a severe brain injury who was known to have "periods of restlessness" was found dead in their wheelchair. The person had slipped partially out of their wheelchair and was found with their lap belt around their neck.

Have you experienced a medical mistake in Manitoba? Get in touch with Marina von Stackelberg at marina.von.stackelberg@cbc.ca.