Critical incident detail unveiled

How many times have Saskatchewan surgeons operated on the wrong body part? Or the wrong patient? Since 2004 the Saskatchewan government has been focused on gathering answers to these and many more questions about patient care and safety.

Province admits incidents are "underreported"

Deborah Jordan, with the Ministry of Health, says as a result of several incidents the ministry has instituted a "surgical checklist" which requires the medical team to confirm a range of key details before operating. (CBC)
How many times have Saskatchewan surgeons operated on the wrong body part? Or the wrong patient? 

How often have nurses sent parents home with the wrong baby? 

Or how often have medical staff sexually or physically assaulted a patient? 

Since 2004 the Saskatchewan government has been focused on gathering answers to these and many more questions about patient care and safety.

All health regions are required by law to report and investigate each case.

Deborah Jordan, executive director of acute and emergency services at the Ministry of Health, says the purpose is not merely to gather the numbers but to "get to the underlying root causes of the critical incident and then make recommendations for how could this have been prevented, what have we learned about this and what recommendations would we make so that something similar does not happen to another patient." 

The ministry has previously reported these numbers in aggregate, but the details have never been shared publicly until now, as a result of an access request by CBC's iTeam.

They show that over the past eight years there has been an average of 144 critical incidents per year in Saskatchewan. 

There has been little change in those numbers during that time. 

It's difficult to compare Saskatchewan to other provinces because there is no nationally agreed upon definition of critical incidents and there is no standard way of publicly reporting them.

Critical surgical incidents tracked

Canadian Institute for Health Information (CBC)
From 2005 to 2013, surgeons operated on the wrong body parts 11 times, performed surgery on the wrong patient once, conducted the wrong surgery on the right patient six times and left "foreign objects" inside a patient 25 times. 

As a result of incidents such as these the ministry has instituted a "surgical checklist" which requires the medical team to confirm a range of key details before operating. 

"We have the right patient. We have the right side. We have the right body part," explains Jordan. "You know, it's a walk through."

And once the surgery is done, all of the instruments are supposed to be counted to ensure nothing is left behind. 

The ministry says 98 per cent of surgeries in Saskatchewan are now conducted using this checklist tool. By 2011, the tool had been adopted by all health regions.

Government monitoring patient safety

The ministry is tracking much more than just surgical errors. 

It also has discovered that on one occasion in 2008, an infant was "discharged to the wrong person."

It found that over the past eight years, 81 patients killed or attempted to kill themselves, 25 patients "disappeared," often simply wandering off, and in 16 cases a patient was physically or sexually assaulted by an employee of a health region. 

The ministry says every criminal case was reported to police. 

Jordan says tracking this sort of detail can alert officials to troubling trends and encourage them to make changes. 

For example, Jordan says the ministry has noted that since 2005, 120 patients have died due to a fall, an average of 15 per year. 

She suggests most of those falls would have happened in senior’s homes. In light of this information, Jordan says the ministry has put in place province-wide recommendations aimed at reducing falls.

Jordan says that the system is working for most Saskatchewan patients, but not all.

"Because if you're the patient or the family members of that patient, the one or two percent, and the fact that the other 98 or 99 per cent of surgeries went well was not comforting to me if I've been harmed in some way."

Gaps in "critical incident" reporting

Melinda Braun sued her surgeon after some medical tape was left inside her body. (CBC)
Melinda Baum is one of those patients who was harmed in the system.

A piece of surgical mesh ended up puncturing her bladder, which led to almost four years of agony and complications. 

Baum successfully sued that surgeon for medical malpractice. 

She says the surgeon's colleagues identified the problem, but they were reluctant to discuss what went wrong.

"When I figured out what was happening I asked ‘well, did she just leave that in there’ and they were pretty evasive," Baum recalls. "They weren't wanting to rat her out I don't think."

The judge in Baum's case concluded that rather than taking responsibility for her failure to identify her error, the surgeon pointed fingers at others.

"She attempted to shift blame to the nurses and even to Ms. Baum," the court document says.

Baum found this failure to accept responsibility most frustrating of all.

"It also makes me wonder what kind of world do we live in where doctors feel that they can't own up to mistakes and have someone else fix it. How did we get there?" 

Baum's case may qualify as a "critical incident" under the ministry's guidelines, but according to her lawyer it was never reported to the ministry and a critical incident report was never created. 

The health region says the incident should have been reported to managers in the region, but that only happened five years after the surgery. It notes this incident happened just a few months after the new critical incident reporting law was established.

It says it continues to teach its staff and doctors about what constitutes a critical incident, and the requirements for reporting. 

Ministry acknowledges "under-reporting"

While Jordan can't discuss Baum’s case, she's anecdotally aware that some critical incidents aren't reported to the ministry. 

"It tells us that we have a lot more work to do."

She says some health care workers might be afraid to acknowledge mistakes. She says it takes time to change an entrenched culture and make it more open.

"This isn't about you or I blaming one another for when it went on but that we recognize something occurred and that as a health care team, we say, look, this went wrong for our patient. Let's go back and walk through this and see why. Were we rushed? Did we not go through the checklist?"

She notes that there are 40,000 health care workers in Saskatchewan and about 120 thousand admissions to hospital every year so there are plenty of opportunities for error. 

And she says the only way change will happen is if everyone feels free to admit or identify mistakes and immediately address them. 

Baum says if that happened in her case she would have been able to avoid almost four years of surgeries, medical appointments and suffering.

She says her case was never declared a critical incident and investigated by the health region, which in her mind is a lost opportunity.

After she won her court case, Baum took the initiative to meet with officials at the Cypress Health Region.

"I had some recommendations." she says. "You can do this better. We can all do this better."

About the Author

Geoff Leo

Senior Investigative Journalist

Geoff Leo has been a reporter for CBC News in Saskatchewan since 2001. His work as an investigative journalist and documentary producer has earned numerous national and regional awards.