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 times in 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
