Manitoba Health releases latest report on critical healthcare incidents

A patient died the day before cardiac surgery after needlessly waiting months for a follow-up appointment. That was just one of the incidents released in the province's latest report on critical incidents in the healthcare system.

The list, which covers October to December 2014, contains sparse details on more than 50 critical incidents. A critical incident is defined as "an unintended event that occurs when health services are provided to an individual and results in a consequence to him or her that is serious and undesired" such as death or injury.

"It's disturbing to see so many of the categories, the types of things that are happening… that seem to be happening over and over and over again," said Darrell Horn who investigates critical healthcare incidents with Healthcare System Safety and Accountability Inc. "I don't see an awful lot of things that strike me as new or unusual here. It's sort of the same old, same old." 

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Ten of the incidents resulted in patient deaths.

"Patient identified as needing cardiac surgery," the report stated on the death involving the cardiac patient. "When contacted by cardiac surgery access coordinator patient indicated desire to speak with surgeon. No follow-up appointment was made."

Months later, the province says the patient contacted the chief surgeon's office to indicate that no follow-up appointment had been made and an expedited appointment and timely surgery were scheduled.  However, the patient ended up dying the day before going under the knife.

Officials with the Winnipeg Regional Health Authority couldn't offer comment on this specific incident, but agreed that many of the incidents are a result of communication issues.

"One of the themes that we have found in some of our investigations is the challenge with the communication and following through with all of the referrals and ensuring that those are made, documented and followed up on," said  WRHA VP and chief nursing officer Lori Lamont.

"Communication is always one [area] where there is opportunity for improvement," she added. 

Communication is key

Lamont expects following through referrals will be simplified with as more and more departments switch to electronic patient-tracking systems.

"We have been building our electronic systems in our specialty clinics and outpatient areas so we can track when people are referred when they need to be."

She said it used to be much harder when records were tracked solely on paper.

But Horn believes the switch to digital might not be working as hoped.

"You can get a machine to do something, but it doesn't eliminate human work," Horn said. "We haven't got to the point yet to make these systems efficient enough to keep these types of communication errors from occurring."

"It's not just a provincial problem, it's a national problem," he added.

He said studies have shown adverse events in health care are the third leading cause of death for Canadians and part of a troubling trend in Manitoba.

His advice for those in the healthcare system, or who have loved ones needing medical help – be vigilant and speak up.

"If you're supposed to have an appointment to see a specialist and it doesn't happen, follow up," Horn said.

Other incidents in the latest report from Manitoba Health include:

• A Patient underwent extensive surgery for carcinoma. Two months later, the surgeon indicated the need for referral for possible chemotherapy based on pathology. There was no record of a referral being sent. A number of months later, the patient underwent surgery for a ventral repair by the same surgeon. Biopsies during the second surgery indicated metastatic cancer.
• Diagnosis amended in two pathology reports. One patient received unnecessary surgery, the other has a potential delay in treatment.
• Personal care home resident received their usual medications. Fifteen minutes later, their lips & tongue were noted to be swollen. A white powder, later found to part of a denture cleaner tablet, was noted in the resident's room and on the resident. The patient died eight hours later in hospital.
• Delay in assessment of a patient with complex medical issues resulted in ICU admission, subsequent cardiac arrest and death.