WINNIPEG — A patient supposed to stay at the hospital overnight for observation is inadvertently discharged home. The same person comes back the next day in cardiac arrest and dies.
This hospital horror story is one of 87 in the latest publication of Critical Incidents Reported to Manitoba Health.
The quarterly reports posted on Manitoba Health’s website detail critical health incidents that happen across Manitoba and result in major injury or death. Legislation was introduced for mandatory critical incident reporting across the health system in 2006 to support “a culture of learning and openness.”
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The names of hospitals and personal care homes involved in the incidents are not documented in the reports.
The most recent report shows incidents between Oct. 1 and Dec. 31, 2013. In the list of 87 incidents, there are seven reported deaths.
READ MORE: Click here to read full report
Included in the list of incidents:
- PCH resident had unwitnessed fall. Fractured femur. Fall mat and low bed not in use at time of the fall.
- Patient referred to Cancer Care Manitoba from emergency department in August 2012. No record of referral; patient not aware of same. Once discovered, cancer had progressed.
- Stretcher was tipped over when being moved to ambulance. Slippery pavement. On initial assessment, no injuries noted. In emergency department, found to have displaced clavicle.
- Critically ill patient was being transferred by STARS in snowstorm-like conditions. En route, portable oxygen source depleted. Hypoxia led to hypotenstion and cardiac arrest. Later died in hospital.
- Patient had abdominal surgery in September 2013. Hardened area near incision remained two months later. CT scan shows surgical gauze left in abdomen. Second surgery required for removal.
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