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Critical Care Incidents

Introduction

The number of reported critical incidents in Manitoba personal care homes and hospitals declined last year compared to the year before. There were 526 incidents in 2011-2012, down from 649 in 2009-2010, according to the province.

People suffering falls in nursing homes and hospitals remain the greatest cause of critical incidents which are defined as unintended incidents during the course of health-care delivery in which harm is caused to a patient.

Most of the critical incidents last year, 52 per cent, were falls, while 37 per cent were the result

Deaths are also on the decline: In 2010-2011, 14 per cent of critical incidents resulted in death, while last year the rate was 10 per cent. Fifty-four patients died last year. Here's some of the incidents involving death and the cause.

Issues with diagnosis

  • An eight-month-old baby repeatedly came to the emergency department and each time was diagnosed with stomach flu and discharged. One week later when the condition hadn't improved the baby was admitted to hospital and then the intensive care unit where the baby died of cardiac arrest.
  • A woman pregnant with twins came to emergency complaining of abdominal pain, cramping and slight bleeding. Not assessed by obstetrics. The babies later died.
  • A delay in a decision to perform a c-section. Separation of the placenta from the wall of the uterus. Baby subsequently died.
  • Hospital staff discharged a patient without recognizing that the patient had elevated levels of troponin, a protein that can indicate heart damage. The patient later died after calling 911 for an ambulance.
  • Patient admitted to intensive care unit with low blood pressure. Troponin level was wrongly reported resulting in failure to perform angiogram. Condition deteriorated and patient died.
  • A nursing home resident suffered two falls in two weeks. In neither fall was an x-ray done. The patient was given an antibiotic for pneumonia, but died. Autopsy revealed three fractured ribs.
  • Care workers took too long to recognize and respond to the declining condition of a patient with ulcerative colitis. After a number of weeks patient transferred to Winnipeg, but died.
  • Patient sent to emergency by family physician. Complaining of weight loss, trouble swallowing, and weakness. Doctors unable to find the cause despite extensive tests. Discharged from the hospital. Collapsed at home and died.
  • A suture placed in a vein during coronary artery bypass surgery caused blocked flow of blood from upper body and brain. Not detected for eight hours. Patient died of lack of oxygen to the brain.
  • A feeding tube to the small bowel punctured the lung of a patient. X-ray read incorrectly. Repeat x-ray showed the error. Patient's condition deteriorated despite treatment. Died two weeks later.
  • A patient came to emergency with breathing problems. Given oxygen and discharged. Came back to ER complaining of breathing problems. Diagnosed with pneumonia. Later died.

Issues with speed of treatment

  • Husband visiting his wife in hospital collapsed in the hallway. Taken to emergency department By the time a physician saw him 15 minutes later he was dead.
  • A patient came to the emergency department with a case of septic shock, a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure. It has a high death rate and requires immediate treatment. The patient was triaged as urgent but treatment was delayed. Admitted to the intensive care unit but died several days later.
  • A nursing home resident in a remote location became acutely-ill requiring hospitalization. However, there was a delay in finding a bed. The patient died in hospital one week later.
  • Delay in treating a patient with septic shock in the emergency room. Admitted to intensive care unit but died several days later.
  • Two day delay in diagnosing a fractured hip in a nursing home resident. Condition declined after surgery and the patient died one month later.

Choking on food

  • A cancer patient in a nursing home with swallowing difficulty, choked on food. Attempt to remove the food failed and the patient subsequently died.
  • During a meal a patient collapsed holding throat. Heimlich maneuver attempted without success.
  • A stroke patient in a nursing home was on a minced diet because of difficulty in swallowing. Given a whole sandwich by mistake and choked to death despite attempts to clear airway.

Issues with ambulances

  • No emergency medications were available in an ambulance transporting a patient with cardiac problems. The patient died en route to hospital. Also in 2011 ambulance crews called to the Garson home of a woman suffering a heart attack arrived with non-functioning equipment. The woman died before reaching the hospital.
  • A patient suffering a heart attack called for an ambulance, but the unit broke down on route causing a delay while a second ambulance was dispatched. The patient later died.
  • Ambulance called for nursing home patient did not arrive for one hour. Patient died after admission to hospital.
  • Patient died after a "miscommunication" between dispatch and the ambulance about the patient's location.

Issues with equipment

  • Care workers moving a patient dislodged a temporary pacemaker causing it to fail. Staff unable to insert a permanent pacemaker "due to the patient's diagnosis." The patient subsequently died.
  • An obese patient went into cardiac arrest after the bed's electric controls malfunctioned. The bed could not be positioned flat for CPR and the patient died.
  • Nursing home resident died when head became caught between top rail and mattress of bed.

Issues with drugs

  • A patient was given blood thinner before doctors had ruled out the possibility of internal bleeding, A CT scan showed a tear in the thoracic artery. Patient died in the operating room.
  • A patient known to be on Warfarin, was admitted to the emergency department. Patients using this drug are susceptible to internal bleeding and must have their blood-clotting ability measured frequently. However, this test was not done on admission and the patient later died of a hemorrhagic stroke.

Issues with patient's condition at discharge

  • A patient with multiple problems discharged from hospital despite shortness of breath and confusion. Returned to emergency room and died.
  • A patient came to the emergency department complaining of chest pain. Left after negative test results. However, the patient later collapsed at home and died three days later in hospital.

Issues with falling

  • Hospital patient died of bleeding in the brain after falling.
  • Patient fell from chair to floor and struck head. Had a seizure and died.
  • Nursing home resident fractured arm and hip in a fall. Following surgery developed pneumonia and died.
  • Bone fracture undetected in patient who had had a fall. When fracture eventually discovered an aniticoalgulant administered in error, resulting in further delay in surgery. Patient died.

Other causes

  • A nursing home resident suspected of swallowing soap was brought to the emergency department . Treated for allergic reaction but died 12 hours later.
  • A patient came to the emergency department complaining of severe abdominal pain. While there the patient suddenly deteriorated and died after admission to the intensive care unit.

[Interactive by Justin Anders & John Drabble/CBC]