Province's latest critical incident report details death after patient given wrong dose of medication
A doctor is seen in this stock image.
WINNIPEG -- The province’s latest critical incident report features a patient’s death after they were given the wrong dose of medication; a personal care home resident whose wheelchair was crashed into a door; and a cancer patient who missed their window to get a transport due to a delay in referral.
The report detailed a total of 33 critical incidents reported to Manitoba Health between July 1, 2019 and Sept. 30 2018, 12 of which resulted in death.
THE WRONG DOSE
The report covers one incident of a patient who needed urgent treatment with an intravenous medication, but the dose of the medication was miscalculated and the person received more than required. The patient then went into cardiac arrest and died, the report said.
A WHEELCHAIR CRASH
Another critical incident in the report involves a resident with a progressive neuromuscular disease who was admitted to a personal care home, where it was determined they could not be positioned properly in their wheelchair to allow them to use their head controls independently. Staff therefore moved the patient around using the head controls. One time while trying to leave the building, staff lost control of the wheelchair and it crashed into electric doors and knocked the doors off the track. The resident’s leg was pinned and they suffered a fractured tibia/fibula. The report said they are awaiting orthopedic consultation.
A DELAYED REFERRAL
The critical incident report also covers a patient, receiving cancer treatment, whose referral to the blood marrow transplant clinic was delayed. Due to this delay the patient missed their window for being a transplant candidate.
SEVERITY OF INJURY NOT RECOGNIZED SOON ENOUGH
Another health-care delay occurred when an out-of-hospital patient suffered a traumatic injury. Emergency medical services were deployed, but there was a delay in realizing the severity of the patient’s injuries and need for transfer to a trauma centre. The patient died.
TEN TIMES THE ORDERED DOSE OF METHADONE
Another incident reported to Manitoba Health includes an inpatient at a mental health unit who received methadone as part of their morning medication. This patient was found outside the facility with unconscious, floppy uncoordinated movements, pinpoint pupils, as well as slow, shallow breaths. They were brought to the emergency department where it was determined they had received 10 times the ordered dose of methadone. The reports says the patient was given naloxone six times while at the emergency department, and once the patient went back to the mental health unit they continued to require naloxone because of respiratory depression.
A DEATH BY SUICIDE AT A MENTAL HEALTH UNIT
The critical incident report details a patient who was admitted to an acute mental health unit following a suicide attempt. The person died by suicide while at the unit.
A PERSONAL CARE HOME ATTACK
According to the report, a resident at a personal care home had an unwitnessed fall. The resident was found on the hallway floor, while a co-resident kicked her. The resident fractured their hip, which required surgery. The report notes that given the history of the two residents, it’s believed she was pushed to the floor by the co-resident.
A MISSING PATIENT
One critical incident happened after a patient went missing from the patient-care area, but the procedures to alert the staff and security weren’t initiated. They were later found dead.
Another critical incident occurred when a personal care home resident was given a cup of hot tea. The report says tea spilled on the right side of their body and burned their abdomen, hip and leg. Extensive ongoing treatment is required.
A DEADLY FALL
The report also details a patient, who was missing from their room, found in the courtyard below the room’s window. The patient died. The report says it’s not known if the fall was accidental or intentional.
Legislation in Manitoba defines a critical incident 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.” These incidents can include death, injury or disability and are not a result from a person’s underlying health condition or the inherent risk that comes from providing a health service. The legislation applies to regional health authorities, hospitals, personal care homes, land and air ambulances, the Selkirk Mental Health Centre, CancerCare Manitoba and Diagnostic Services Manitoba.
The entire critical incident can be found online.