Incorrect cancer diagnoses, amputation from flesh-eating disease among Manitoba critical incidents last spring

A baby gets two invasive procedures—a chest tube and a central line—without pain medication or sedation.

Another baby, one of two intubated twins, has a cardiac arrest while waiting in a remote area for a transport team tied up with another call.

An incorrect diagnosis of cancer causes one patient to be entered in the palliative care program unnecessarily; another woman required palliative care after her pelvic cancer was missed two years ago.

These are among 28 critical incidents in Manitoba Health's latest quarterly report that details events in healthcare that resulted in serious harm to the patient. Three of the incidents resulted in deaths.

They occurred between April 1 and June 30 of 2018 at hospitals across Manitoba, which are not named.

"It's difficult to read these reports. Because there's people. There's real people behind them. And there's families. And there's health care providers," said Laurie Thompson, executive director of the Manitoba Institute for Patient Safety.

"You just know the impact that these circumstances can have on people. And in some cases, the extreme tragedy of death. Every one has to be taken seriously in the spirit of being courageous to try and figure out what might have gone wrong and try and prevent it from happening in the future." 

A man died after his coronary artery was cut by a wire during an angiography— which is an X ray of blood vessels—and he was sent to a regular ward after surgery instead of the cardiac unit.

A patient had to have their leg amputated after first going to a rural emergency department with a swollen leg with open sores, following three days of nausea and vomiting at home. They were resuscitated because of low blood pressure.

The patient had to wait 18 hours in an emergency room, had more delays in seeing a specialist, and ultimately was diagnosed with necrotizing fascititis, commonly known as flesh-eating disease, and septic shock, prompting emergency surgery to remove the leg.

Other incidents in the report:

• A pediatric patient needed a blood transfusion and admission to the ICU after getting an overdose of Heparin, which is an anti-coagulant medication, after the required two-nurse check did not happen when programming the IV pump.
•  A senior with dementia was wandering the hallway, began shouting and kicked down a door to another senior's room, who pushed the person back into the hallway and caused multiple broken bones.
• Someone had damaged tissue removed from a wound on their foot, which then wouldn't stop bleeding. The vascular surgery team was consulted and planned to see the patient the next morning; overnight their blood pressure and red blood cell levels dropped. The patient had a cardiac arrest and died the next day. 
• A patient in a personal care home was transferred manually instead of with the required mechanical lift, causing a broken hip.
• A child required ICU admission three weeks after discharge from hospital, when the diuretic medication that led to the first admission was discontinued but later erroneously ordered to be resumed.
• A person suffered a Code Blue (cardiopulmonary arrest) after receiving ten times the ordered dose of a powerful cardiac medicine.
• A woman was diagnosed with cervical cancer after four PAP smears were inaccurately interpreted as having no cancer present.
• Several patients fell and injured themselves when left unsupervised.

Incidents will be reviewed

Each of the events will be reviewed, and the findings will be reported to affected families with an apology, said Thompson. Findings and recommendations are shared by the institutions with staff for learning purposes, she added, as the pursuit of safety does not end.

"It's a constant pursuit because people are human and we hope that organizations can learn from these tragedies. So that they can help be prevented in the future."

Thompson added World Patient Safety Day was September 17, and its theme was 'speak up for patient safety.'

The Canadian Patient Safety Institute's patient safety week is the last week of October, and its theme is 'conquer the silence,' things Thompson said she thought of while reading the incidents. 

"Everybody who works in health care has a responsibility for reflecting on their own practice and to speak up if they see something happening that they don't think is right, as patients do as well."

The two page report is available online.