Postponed surgery, other health-care delays preceded deaths, critical incident reports say

Postponement of elective surgery, health-care equipment failures, and falls are among the problems that led to deaths in 22 critical incidents in Manitoba health-care settings over the first nine months of 2023.

In addition to the 22 deaths, another 90 critical incidents caused major injuries, including amputation, surgery performed on the wrong body part, and completion of the incorrect procedure, quarterly reports from Manitoba Health say.

Critical incident reports are made when people using the health-care system suffer serious, unintended harm. They spark reviews that can prompt recommendations for improvements.

The reports are summarized in one or two sentences and published online every three months.

The province recently released three quarterly critical incident report summaries after Manitoba Health started posting them within six months, instead of within a year, which had been the practice.

The deaths in the nine months covered in the three reports include two where a medical device or equipment failed, one in which a person fell from a transfer device, and another in which a medical device came dislodged.

Delay cited 21 times

Postponed elective surgery resulted in death in one case, and a delay or lack of earlier care were mentioned as factors in 10 of the deaths.

When critical incidents that caused major injuries are included, the word delay crops up 21 times in the three reports, and early or earlier are used 32 timesin phrases such as "an opportunity for earlier recognition and intervention was not realized."

References to "skin tissue breakdown" and "pressure injury" also show up repeatedly. Those terms generally indicate bedsores, which can develop when patients who cannot move on their own are not turned often enough.

Darlene Jackson, president of the Manitoba Nurses Union, said her first thought after looking at the reports was that 99.9 per cent of the critical incidents were preventable with adequate staffing.

The repeated indication of bedsores skin breakdowns or pressure injuries are mentioned in 29 incidents is a sign that there weren't enough staff to make sure people were turned frequently and given adequate skin care, she said.

"Those are totally, totally preventable," she said. "These injuries aren't going to stop unless we have the adequate staffing to address them."

Similarly, falls are often a result of inadequate patient oversight, she said.

"If there's someone there to keep an eye on them, there's less chance that they're going to try and get up by themselves and fall."

Nurses know they should spend more time with their patients, but they're doing the best they can with an unreasonable workload, Jackson said.

"I hear from nurses all the time that they go home feeling angry and frustrated that they were not, you know, they were not able to provide the care they know that they should be providing, and they know that the patients deserve."

There aren't enough nurses available to fill all the positions that are needed in the system, so the long-term solution is to continue to retain current nurses and work to educate more, Jackson said.

In the meantime, health-care facilities can hire more support staffwho can do things such as turning patients or helping them so they don't fall, she said: "That's how we're going to deal with this is by increasing staff."

Recommendations implemented: doctor

Dr. Manon Pelletier, chief medical officer at Winnipeg's Health Sciences Centre, said Monday that the system follows recommendations that come out of critical incident reviews.

"We have timelines that we have to deliver on those recommendations and implement them," she said.

"Sometimes it's an entire site-wide rollout of teaching, so it can take some time, but they do occur, and all of those learnings go back to the unit where it occurred or to a larger site, depending on what the learning is from that event."

In addition to releasing the reports more quickly, the province is working on associated patient safety learning advisories that sometimes come out of the critical incident reviews, a provincial spokesperson said.