Manitoba Health

Patient Safety Learning

Critical incidents and other patient safety incidents are reviewed to identify ways in which the health care system might change so that health care delivery can be made safer.

All health authoritiesare required to share the lessons learned from these events as applicable. This learning may be the result of the review of one event or a number of similar events.

Patient Safety Learning Advisories (PSLAs)

The department began posting these patient safety learning advisories in November 2014, to share with a larger public audience. This responsibility has transitioned to Shared Health.

For more information, please visit Patient Safety Learning - Shared Health - Health Providers (sharedhealthmb.ca)

All reports are in Adobe Acrobatformat, and currently available in English only.

Failure to Communicate Diagnostic Investigation Findings Aggregate Analysis of Stage 3 and 4 Pressure Ulcers Resident and Co-Resident Aggression Failure to diagnose serious malignancy Inadvertent Administration of Neuromuscular Blocking Agent during Procedure Pressure Injury Related to Use of Traction Equipment Failure to recognize perforated viscus following surgery Abscess Related to Insect Bite Choking in a Personal Care Home Resident Discharge Instructions in the Emergency Department Error Related to Lithium Dosage Conversion Fall from Bed with Serious Injury Cancer Diagnosis Communication to Patient Discrepancy between Pathology Specimens on Two Occasions Specimen Referred for Testing Out of Province Transporting Specimen for External Consultation IV Insertion Prior to Radiology Examination Discrepancy in Diagnosis Based on Biopsy Results Delay in Receiving Laboratory Test Results Pressure Ulcer Retention of a foreign body in a patient after surgery Delay in Treatment Pressure Ulcer Communication and Documentation of Allergies Development of a Pressure Ulcer in a Hospitalized Patient Communication of Biopsy Results & Treatment Delays Fall from Radiation Treatment Table Melanoma Misdiagnosis The Role of Automatic Doors in Patient Fall Improper Footwear results in Changes to Falls Prevention Management Sling Loop Migration Contributes to Fall from Client Lift Aggressive Client Behaviour Contributes to Client Harm Development of a Pressure Ulcer in a Hospitalized Patient Hip Fracture Related to a Patient Fall Delay in Treatment Neonatal Death Neonatal Death Deteriorating Patient Condition Associated with Medical Gas System Dysfunction Failure to Provide High Flow Oxygen during Intra-facility Transfer Post Endoscopy Complications To Reduce Gastric Volvulus Delay in Treatment Referral for Pulseless Limb Deterioration in Patient Condition Related to Incorrect Kaofeed Tube Placement

Burn Injury During Removal of a Fibreglass Cast Stage 3-4 Pressure Injuries in Long Term Care Residents Incorrect Surgical Site Misreading Pathology Report Results in Omission of Treatment Wrong Site Surgery Fall Resulting in Fracture Failure to Change Treatment Plan Following Critical Test Result Fall with Hip Fracture Delay in Diagnosis/Treatment Pressure Injury Communication about Patient Goals of Care Medication Adverse Event Surgical Incision Awareness Gaps in Wound Care Services in Home Care Environment Unintended Dislodgement of Feeding Tube Delayed Diagnosis of Abdominal Pain Fall Resulting in Fracture Medication Error - Missed Dose of Neupogen Delay in Treatment Following Outpatient Surgical Procedure Unwitnessed Fall Improperly Charged Defibrillator During Cardiac Arrest Foreign Body Left in Client Fall from Mechanical Floor Lift Medication Administered to Incorrect Client Fall Resulting in Fracture Wrong Site Surgery Pressure Injury Medication Adverse Event in an Infant Myomectomy Complications Delay in Treatment Delay in Treatment Lack of Documentation Death by Suicide in Facility Aspiration Resulting in Death Delayed CT Scan Fall Resulting in Fracture Humeral Head Fracture Humeral Head Fracture Streptococcal A Sepsis Resulting in Death Incomplete Surgery Missed Amended Pathology Report Communication Between Departments All Results from Diagnostic Imaging Not Addressed Incorrect Surgical Procedure Lap Belt Strangulation Unwitnessed Fall Resulting in Fracture Methadone Dosing Error Fall From Bed With Fracture Sling Loop Migration Causing Fall From Ceiling Track Lift