Critical Incidents Reported to Manitoba Health

Transcription

1 Critical Incidents Reported to Manitoba Health April 1, 2011 March 31, 2012 Degree of Injury Description Incorrect patient taken for day surgery as patient verification procedure not followed. Procedure attempted but not Recovered without adverse effects, no delay in discharge. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident had unwitnessed fall resulting in fractured femur. Surgical Later died. Emergency surgery. Sudden deterioration in oxygen saturation levels. Admitted to ICU. 10 day delay in discharge. Patient had witnessed fall resulting in intracranial bleed. No surgical intervention indicated. Returned to PCH. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Minor Physician ordered concurrent radiation therapy & chemotherapy. Chemotherapy regimen not initiated with start of radiation therapy. Effect on patient unknown. Patient had difficulty standing, so was eased to floor. Fractured fibula. Cast applied. Patient had unwitnessed fall prior to admission. Fractured hip. Surgical Underwent rehabilitation. Patient caught arm in sliding doors while leaving Emergency Department. Fractured wrist. Surgical repair. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Daily dressing changes to ulcers on toes at community wound care clinic. Three days later, patient presented to Emergency Department. Amputation of toes required. Grossly elevated blood sugar following outpatient clinic medication treatment. Required hospital admission. Chemotherapy not begun as ordered 3 months earlier. Further progression of disease and failure to meet standard of care. Recovered with no known long term effects. Lab reported low potassium level. Patient suffered cardiac arrest. Successful resuscitation. Repeat potassium level grossly elevated. Following treatment, patient fully recovered. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Patient had unwitnessed fall resulting in fractured hip. Patient underwent rehabilitation. Patient admitted to hospital following a fall. Developed paraplegia in hospital. MRI showed spinal tumor. Radiation therapy. CT scan done 10 days later showed no tumor. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident, walking with walker, transfer belt & health care aide, became weak. Lowered to floor. Fractured patella. Surgery not indicated. Underwent rehabilitation therapy. Minor Patient in ED received over 3 times the prescribed dose of low molecular weight Heparin. Admitted for observation. Discharged 48 hours later with no adverse effects. PCH resident had unwitnessed fall resulting in fractured hip. Outcome unknown. Patient with previous history of falls at home had unwitnessed fall resulting in fractured hip. Surgical Delay in treating patient with septic shock triaged as urgent in Emergency Department. Admitted to ICU. Died several days later. Unknown Biopsy sample not processed correctly, reducing the amount of clinical information available to physician. Impact on patient unknown. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident had unwitnessed fall resulting in fractured hip. Surgical Unknown Patient assaulted by another patient. Sustained no significant physical injuries, but later died as a result of multiple underlying conditions unrelated to the event..

2 Over 3 months, patient s pressure ulcer to heel deteriorated. Resulting infection of the bone required treatment with antibiotics. Discharged from hospital following surgery. Required second surgery to repair esophageal perforation that may have occurred during first surgery. Patient had unwitnessed fall. Intracranial bleed. Family decided to provide palliative care. Delay in accessing inpatient bed for acutely ill personal care home resident in remote community. Resident died in hospital one week later. PCH patient unknown to be non-compliant in asking for assistance had unwitnessed fall. Facial fractures. No surgery indicated. Patient with suicidal ideation to Emergency Department. Left without being assessed after 3 hour wait. Witnessed jumping into river. Rescued by paramedics. Admitted to psychiatric unit. During 2 week hospitalization, pressure ulcer deteriorated. Outcome unknown. On admission from hospital to long term care, area of deep tissue injury noted. Infected stage 3 pressure ulcer. X-ray shows nasogastric tube inserted into trachea. Delay in relaying this information from Radiology to unit. Admitted to ICU where patient died 3 days later. Family transporting PCH resident in wheelchair outside building. Wheelchair hit curb. Resident fell out of chair. Fractured femur. Unable to perform surgery. Splint applied. Resident recovered. Resident attending recreational activity in personal care home had unwitnessed fall resulting in fractured hip. Surgical PCH resident had seizure followed by fall. Fractured humerus. Surgical Coronary bypass surgery. Subsequent myocardial infarction. Second bypass surgery required. Surgery successful. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident who desired their independence had unwitnessed fall resulting in fractured elbow. Surgical PCH resident non compliant with safety measures had unwitnessed fall resulting in fractured hip. Surgical Despite nursing care in the home, wound to back deteriorated in immobile patient. Concerns regarding the timeliness of wound care nurse specialist consultation. Patient with chest pain diagnosed with myocardial infarction treated with thrombolytic agent. The next day, patient s speech was slurred. Diagnosed with intracranial bleed. Condition deteriorated and patient died. PCH resident pushed by another resident. Fell and fractured wrist and hip. Surgical Patient required medication to maintain blood pressure following open heart surgery. Received 4 times prescribed dose due to pump programming error when medication solution concentration changed. Died 3 weeks later PCH resident with end stage cancer and swallowing difficulty choked on food. Attempt to remove food unsuccessful. Patient died. Patient had Blakemore tube inserted to control esophageal bleeding. During follow-up endoscopy, esophageal tear noted. Deterioration of pressure ulcer to coccyx in PCH resident confined to bed. Issues identified with communication of change in care plan. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Patient developed pressure ulcer to coccyx & sacrum. Later died due to complications unrelated to pressure ulcer. PCH resident developed infected stage 3 pressure ulcer. Advanced wound care provided. PCH resident had witnessed fall resulting in fractured shoulder and hip. Hip surgically repaired. Patient had unwitnessed fall resulting in fractured hip. Surgical repair. Patient had elevated blood pressure & electrolyte imbalance following surgery. Found to be severely dehydrated. Extended hospital stay required. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident, reluctant to ask for assistance, had unwitnessed fall resulting in fractured hip. Surgical

3 Patient had unwitnessed fall. Did not call for assistance and was wearing stockings at time of fall. Fractured elbow and hip. Surgical repair. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident developed infected wound to sacrum and coccyx requiring antibiotic therapy. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident had unwitnessed fall. Had urinary tract infection. Fractured hip. Surgical repair Delayed treatment of cardiac patient en route to hospital by EMS as no emergency medications available in truck. Patient died. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Patient later died. Patient in ICU with multiple medical co-morbidities and sepsis. Received incorrect intravenous solution in error. Experienced low blood sugars and seizure activity. Died one month later. Temporary pacemaker wire dislodged during patient repositioning. Pacer not functioning. CPR begun. Unable to insert permanent pacemaker due to patient's diagnosis. Patient died. PCH resident with very anxious behavior had witnessed fall resulting in fractured femur. Surgical Undergoing outpatient cancer treatment. History of weakness with periods of fainting. Fell, hit head, lost consciousness. Transferred to hospital and later discharged. In active labor. Fetal heart rate normal. Once on unit, difficulty detecting fetal heart rate. Poor Apgar scores at birth. Resuscitation of baby unsuccessful. Two cognitively impaired residents, one pushed the other. Patient pushed sustained fractured femur. Died several weeks later. PCH resident had unwitnessed fall. Intracranial bleed. Outcome unknown. Unknown To Emergency Department with seizures, alcohol withdrawal and abdominal pain. Delay in reading of abdominal CT scan. Bowel perforated with subsequent sepsis. Surgical repair. Discharged 2 weeks later. PCH resident developed pressure ulcers on heels. Condition declining for some time. Determined to be Kennedy Terminal Ulcers, common in dying patients. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Patient with multiple medical conditions admitted to PCH with unstageable pressure ulcers to both ankles. Advanced wound care provided. Patient referred for excision of dysplasia. Procedure delayed for 6 months at patient s request. Once completed, showed invasive cancer. Delay in procedure did not result in progression of cancer. Discharged from Dialysis without receiving antibiotics. During next dialysis treatment, required admission to hospital due to sepsis. Outcome unknown. While being transferred in the home with mechanical lift, patient slipped out of sling and hit head. Intracranial bleed. Discharged from hospital 2 weeks later. Lost vision when wrong eye treated with gamma knife in In 2011, pain and vision changes in other eye. Has lost vision in other eye. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident had unwitnessed fall resulting in fractured femur. Surgical Patient in Emergency Department with suicidal ideation. No mental health assessment performed nor was patient seen by MD prior to discharge. Attempted suicide 3 days later. To ICU. Discharged and undergoing treatment. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident with dementia lost balance, had witnessed fall and fractured hip. Surgical repair Patient had unwitnessed fall resulting in intracranial bleed. Conservative management. During meal, resident found slumped on table, holding throat. Heimlich maneuver attempted but unsuccessful. Patient known to be on Warfarin presented to ED. No INR testing performed on admission. Hemorrhagic stroke. Patient died.

4 Patient to Emergency Department with severe abdominal pain. Acute & unexpected deterioration. Admitted to ICU. Patient died. Unknown PCH resident given 10 times prescribed dose of Methadone. Treated in hospital and returned to PCH. Discharged from Emergency Department after investigation of chest pain negative. Collapsed at home. EMS defibrillated successfully. Died 3 days later in hospital. PCH resident complained of hip pain, but no history of injury. Surgery completed for fractured hip. Later died due to multiple co-morbidities. Patient had extensive postoperative bleeding following transurethral resection of the prostate (TURP). Admitted to ICU. PCH resident fell while exiting elevator resulting in fractured hip. Surgical Patient with multiple co-morbidities developed embolus to femoral artery. Compromised circulation to lower leg resulted in need for amputation. PCH resident developed Stage 3 pressure ulcer to heel requiring debridement. During open heart surgery, error with right coronary anastomosis. Unstable condition following. Subsequent myocardial infarction. Complications during second bypass surgery. Patient required additional surgeries but recovered. Patient had unwitnessed fall from Broda chair resulting in fractured hip. Surgical Bariatric patient s electric bed controls malfunctioned. Patient had a cardiac arrest. Bed unable to be positioned flat for CPR. Resuscitation unsuccessful. During 3 week hospitalization, blister on heel evolved to unstageable pressure ulcer. Healed with the provision of advanced wound care. PCH resident had witnessed fall resulting in fractured hip. Outcome unknown. Patient identified as high risk for falls had unwitnessed fall resulting in fractured wrist. Cast applied. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Patient transferred from rural Manitoba following motor vehicle collision. Multiple life and limb threatening injuries. Following surgery, signs and symptoms of spinal cord injury identified. Further deterioration in condition. Died five days later. Patient with tracheostomy had unwitnessed fall when oxygen became disconnected. Respiratory difficulty. Successful resuscitation. Admitted to ICU. Patient recovered. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Biopsy confirmed B cell lymphoma. Notification of consultation to CancerCare delayed. In the meantime, developed renal failure that required modified chemotherapy regimen. Delay in diagnosis and treatment of spinal cord compression in patient with history of multiple lytic lesions. Spouse stated patient fell during the night. Intrancranial bleed. Patient recovered. PCH resident admitted with pressure ulcer. Improved with bed rest and pressure reduction strategies. PCH resident in hospital for 9 days following major surgery. Developed unstageable pressure ulcers to both heels. PCH resident receiving end of life care developed stage 3 pressure ulcer during hospitalization. Died 2 days after return to PCH. Patient developed unstageable pressure ulcer following surgery. Outcome unknown. Small bowel feeding tube felt to be correctly positioned according to X-ray. X-ray read incorrectly. Repeat X-ray showed incorrect position and puncture of the lung. Patient's condition deteriorated despite treatment. Died 2 weeks later. Patient received incorrect one time dose of medications meant for another patient. Developed shortness of breath & decreased oxygen levels. Admitted to ICU for 2 days. No residual harm. Delay in diagnosis of an unusual clinical presentation of compartment syndrome. Surgery performed and patient discharged one month later. Elective coronary artery bypass grafting. When sternum opened, vessels at top of the sternum lacerated. Profuse bleeding. Vessels repaired and surgery completed with no further complications. Patient had unwitnessed fall in a dark room after tripping. Fractured clavicle. Arm immobilized in sling.

5 Suicide Fistula needle dislodged during hemodialysis treatment. Patient became unresponsive. Successful resuscitation. Admitted to hospital and discharged one month later. PCH resident with known Stage 1 pressure ulcer to coccyx admitted to hospital for surgical repair of hip fracture. Pressure ulcer deteriorated. Later died due to multiple co-morbidities. Patient discharged from ED without recognition of elevated troponin levels, indicating possible myocardial damage. Three hours later, call to 911. Patient died. Patient to Urgent Care Centre with complaints of chest pain. Not triaged. Spouse told triage was busy and left facility to go to second hospital. Code Blue on arrival at second hospital. Successful resuscitation. Patient on alcohol withdrawal protocol received massive doses of Diazepam over 2 days. Experienced respiratory arrest requiring ICU admission and prolonged mechanical ventilation. Later died. PCH resident wearing anti-slip socks had unwitnessed fall. Two day delay in diagnosis of fractured hip. Surgical Condition declined, died one month later. Patient developed unstageable pressure ulcer. Surgical debridement Wound healing slowly due to multiple co-morbidities. Patient found unresponsive. Resuscitation was to be attempted but no code was called. Patient died. Emergency C-section for delivery of severely premature twins (24 weeks gestation). First baby died at 24 hours of age. PCH resident had unwitnessed fall resulting in fractured hip and pelvis. Surgical Spouse witnessed PCH resident fall. Fractured hip. Surgical PCH resident had unwitnessed fall resulting in fractured hip. Outcome unknown. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Patient had unwitnessed fall resulting in fractured hip. Surgical Patient fell while transferring themselves from wheeled walker to wheelchair. Fractured pelvis. No surgical intervention required. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Patient had unwitnessed fall resulting in fractured hip. Surgical PCH resident, independent in nature, unwitnessed fall resulting in fractured hip. Surgical repair Died 3 days later. Patient with cognitive issues following stroke found crawling out of end of bed with side rails up & bed alarm on. Bed alarm failed to sound. Fractured hip. Surgical Patient admitted for rehabilitation had unwitnessed fall resulting in fractured pelvis. Prolonged hospital stay. PCH resident had unwitnessed fall in fractured hip. Surgical Patient to Emergency Department with suicidal ideation assessed by physician. Patient left ED without medical authorization. Completed suicide at home later the same day. Patient with dementia had unwitnessed fall resulting in fractured hip. Patient with chest pain waited 6 hours in Emergency Department (ED) for treatment. Standard of care not met for patient with chest pain. Angioplasty performed and patient discharged 2 days later. PCH resident had unwitnessed fall resulting in fractured hip. Suffered myocardial infarction in Emergency Department and died. Patient with history of multiple sclerosis, depression and cognitive decline. Receiving rehabilitation for fractured fibula. Had a fall and re-fractured fibula. Patient who had two previously unwitnessed falls found on the floor. Unresponsive and vital signs absent. Patient expressed no wish for resuscitation. Patient underwent procedure and was to receive medication to prevent pregnancy following. Medication was not given. Patient became pregnant. Patient involved in pedestrian vehicle collision. Loss of consciousness at the scene. Sustained major intracranial bleed. Waited two hours for treatment in ED. Implants ordered for breast adjustment surgery were incorrect size. Previously implanted expanders were retained as permanent implants. Patient developed pressure ulcers to heel & coccyx during hospitalization. Resident had unwitnessed fall and struck head. No fall prevention plan in place. Patient died as a

6 result of intracranial bleed. Patient to ED following alleged assault. Left without being seen after 14 hours. 2 days later, required Emergency surgery for perforated bowel. Developed septic shock requiring ICU admission. Patient who presented to ED with syncope due to underlying medical condition had unwitnessed fall. Fractured wrist. PCH resident had unwitnessed fall resulting in fractured hip. Patient outcome unknown. Patient had endoscopic insertion of PEG feeding tube. Insertion was a difficult. Hours later, had cardiac arrest on inpatient unit. Diagnosis of aspiration pneumonia & septic shock. Required ICU care for several weeks following Physician left orders on the electronic patient record following CT scan & lung biopsy. Did not verbally inform anyone of new orders. Computer order entries not seen. Developed pneumothorax. Chest tubes inserted. Patient recovered. PCH resident had unwitnessed fall resulting in fractured leg. Patient outcome unknown. Visitor jumped from facility atrium and struck another patient on the way down. Died 4 days later, other patient hit had minor injuries. PCH resident who was not wearing footwear had unwitnessed fall resulting in fractured hip. Husband visiting his wife in hospital when collapsed in hallway. To ED for treatment. When physician arrived 15 minutes later, patient had died. Patient presented to ED with chest pain. No orders for anticoagulation received. Developed bilateral pulmonary embolism. Admitted to ICU, treated and discharged. PCH resident with osteoporosis had unwitnessed fall resulting in fractured fibula. On return to facility, had a seizure and was returned to hospital. Patient had a witnessed fall from chair to floor and struck head. Had seizure and died.. Patient s Stage 2 pressure ulcer progressed to Stage 3 ulcer over 2 month period of treatment. Following surgery, patient had bronchospasm and cardiac arrest. Suffered anoxic brain injury and died. PCH resident had unwitnessed fall resulting in fractured hip and arm. Surgical Later died as a result of pneumonia and post-operative complications. Patient with dementia called for assistance to the bathroom. While staff turned off the call bell, patient collapsed, hit head and fractured hip. Hip surgically repaired. Patient received prescription antibiotic cream for eye pain. Experienced sudden loss of vision. Seen by ophthalmologist who removed eye 2 days later. PCH resident found on the floor. Ingestion of soap suspected. Treated in ED for allergic reaction, but died 12 hours later. Multiple medical co-morbidities. Suicide PCH resident found dead hanging by belt from housecoat on bathroom door. Had communicated suicidal ideation to son, but son did not inform staff. Patient s low serum sodium level not reported to MD. Unit very busy. Had a seizure the next day. To ED. Patient presented to ED with complaint of chest pain. Spouse requested assistance twice & was told to wait. Patient and spouse went home after 10 minutes and called EMS. To ED and then to cardiac catherization lab with acute myocardial infarction. Patient had unwitnessed fall resulting in fractured hip. Surgical PCH resident known to be difficult to settle to sleep at night. Appeared sleepy and ready to go to bed. Resident refused. Later found lying on floor. Fractured hip. Unknown Patient with chest pain had cardiac arrest. Following resuscitation, central line inadvertently placed in artery instead of vein. PCH resident using walker when they had unwitnessed fall. Fractured hip. New resident being admitted to PCH. Family had stayed to assist in transition, but left PCH to go out for dinner. During this time, patient fell while attempting to sit in chair. Fractured hip. Surgical repair PCH resident presented to ED after a fall. Discharged as no fracture found. 3 days later, presented to ED again where fracture was diagnosed. Patient received additional anticoagulant in error delaying surgery. Patient died. PCH resident had unwitnessed fall injuring head. Required transfer to ED for assessment and

7 treatment. PCH resident with unsteady gait had unwitnessed fall resulting in fractured hip. Surgical repair Patient with multiple co-morbidities hospitalized for 4 ½ months. Developed Stage 4 pressure ulcer requiring surgical debridement. Home care client developed unstageable pressure ulcers to buttocks as a result of malfunctioning pressure relief cushion. PCH resident did not use walker and had unwitnessed fall. Fractured hip and pelvis. Patient developed unstageable pressure ulcers to both heels. PCH resident with cognitive impairment had fall resulting in hip fracture. Surgical PCH resident with cognitive impairment had unwitnessed fall resulting in fractured hip. Surgical repair PCH resident had a witnessed fall resulting in a fractured femur. Surgical PCH resident with cognitive impairment had an unwitnessed fall resulting in fractured hip and arm. Surgical PCH resident pushed by another resident. Fell and fractured hip. Surgical Patient developed pressure ulcer on coccyx following 2 ½ month hospitalization. Died. Patient admitted to hospital with sepsis and small draining opening on coccyx. Area excised by Plastic Surgeon revealing Stage 4 pressure ulcer. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident with need for independence had unwitnessed fall resulting in fractured hip. Surgical Following vaginal delivery, patient experienced massive bleeding. Emergency hysterectomy performed. Unstable following surgery requiring ICU admission. Continued to experience fever and pain following surgery. Second surgery required for exploration found retained surgical sponges. High risk pregnancy due to mother s substance abuse. During vaginal delivery, a trial of vacuum extraction attempted but unsuccessful. Head injuries sustained during birth as well as delay in treating neonatal abstinence syndrome. PCH resident lost balance and fell while trying to help another resident out the door. Fractured femur. Surgical repair. Unknown Patient to ED with laceration to thumb. Four days later, returned to ED with grossly infected wound. Tendon also found to be lacerated at this time. Surgical debridement performed with need for future surgery identified. Patient with cancer participating in clinical trial developed acute kidney and liver failure. Admitted to ICU. Condition continued to deteriorate and patient died of cardiac arrest. PCH resident had unwitnessed fall resulting in fractured hip. Surgical repair required. Patient with dementia developed infection in their toe. Sent for consult with vascular surgeon. Given condition of toe, toe was amputated prior to obtaining consent of patient or family. Unknown While in Radiology suite, severe anaphylactic reaction to contrast material used for imaging. Department had no epinephrine available to treat reaction. Patient sent to ED with respiratory distress. Discharged from ICU 5 days later. Patient receiving Warfarin presented to ED for INR testing. Fell when struck on the head by a closing door. Intracranial bleed requiring neurosurgery. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Patient with Acute Coronary Syndrome and history of stroke had 2 falls. Intracranial bleed. Required Lifeflight transport to Winnipeg for neurosurgery. PCH resident had witnessed fall out of wheelchair after removing tabletop from wheelchair. Fractured hip. Surgical PCH resident independent with ambulation had unwitnessed fall resulting in fractured hip. Surgical Pediatric patient to Recovery Room following nasal surgery with throat pack left in place. Airway became compromised. Required return to OR for removal of the throat pack. Overnight admission to Pediatric ICU for observation. Discharged the following day.

8 Patient admitted to ICU with low blood pressure and possible acute coronary syndrome. Troponin level erroneously reported to be low. As a result, angiogram not performed. Condition deteriorated and patient died. Long term central venous access device not functioning. X-ray show kinked line as well as broken catheter fragments migrated to right atrium & right jugular vein. Unknown Biopsies obtained via endoscopy. Numerous specimens sent urgently to Pathology lab. Specimens did not arrive five days later. Diagnosis delayed as procedure needed to be repeated. PCH resident with acute delirium had witnessed fall resulting in fractured hip. Surgical repair Patient known to be high risk for falls did not call for required stand-by assistance. Unwitnessed fall striking head. Fractured hip. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident had unwitnessed fall resulting in fractured hip. Surgical Patient to ED and discharged the same day with acute renal failure. No treatment provided and no follow-up initiated. One week later, admitted to ICU for emergent dialysis. PCH resident with dementia had unwitnessed fall. Fractured hip. Died prior to surgery being able to be performed. Patient on vasopressors had venous catheter replaced in jugular vein. Internal bleeding resulted. Delay in communication to physician resulted in delay in surgery to control bleeding. Patient in ED had unwitnessed fall resulting in fractured femur. Surgical Patient developed unstageable pressure ulcers to heels during hospitalization. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident had unwitnessed fall resulting in fractured hip. Surgical Resident with osteoporosis found to have fractured femur 2 weeks following surgery for fractured hip. No known mechanism of injury. Unknown Patient discharged from ED during the night. No documentation of confusion on patient record. Found in park 4 hours later. Admitted to hospital for assessment and follow up. Later discharged. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident unbuckled wheelchair seatbelt and & fell after getting up. Documented non-compliance in asking for assistance. Fractured hip and wrist. Surgical Following delivery, dilation and curettage for post-partum haemorrhage. Laboratory results delayed in being reported to unit. Required Emergency blood administration, Discharged after further treatment. Patient involved in motor vehicle crash presented to ED. X-rays of the spine and CT scan of head and neck showed no abnormalities. No other concerning symptoms. Presented to a second ED four days later. X-ray now shows fractured C2 vertebrae. Admitted for spinal stabilization.. Patient with stroke 4 years ago admitted to hospital with new onset seizures. Fell and fractured pelvis. Suicide Patient on mental health unit found unresponsive with a plastic bag tied around head. Resuscitation attempts unsuccessful. No suicide risk assessment Patient with difficulty breathing presented to ED. Found to new cardiac dysrhythmias. Discharged with oxygen. Returned to ED short time later with difficulty breathing. Diagnosed with pneumonia. Prognosis poor. Patient later died. Patient to ED with gastroenteritis. Found to have systemic blood infection. Despite treatment, condition deteriorated. Transfer to tertiary care delayed. Inpatient with documented Stage 2 pressure ulcer. Time spent sitting up in chair limited. Deterioration to Stage 3 pressure ulcer. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident had unwitnessed fall. Found after chair alarm sounded. Fractured femur. Surgical Patient being examined by medical staff as part of admission assessment. Next day, reported to nursing staff feeling violated & assaulted during exam. Police & PPCO notified. Patient with low back pain presented to ED diagnosed with low back strain. Returned to ED 2 days later and found to have ischemic bowel. Surgery performed and admitted to ICU following. Neonate in Intensive Care Unit received fluid bolus of total parental nutrition over short time period.

9 Solution free flowed because IV tubing not inserted in pump. Patient with metastatic disease receiving stereotactic body radiotherapy. Partial radiation treatment to healthy tissue outside the targeted treatment area. Patient on mental health unit developed fever and low blood pressure. Delay in answering medical consultation as urgency not conveyed. Patient diagnosed with urinary sepsis requiring treatment on medical unit. PCH resident had unwitnessed fall resulting in fractured elbow. Surgical PCH resident had unwitnessed fall resulting in fractured hip. Returned to facility for comfort care. PCH resident had fall resulting in fractured humerus. Patient outcome unknown. Suicide Patient found unresponsive with bag over head and towel wrapped around neck. Resuscitation unsuccessful. No documentation of suicide risk assessment. Patient s blood levels confirmed toxic levels of Dilantin. Handwritten prescription misread by Retail Pharmacy. PCH resident had unwitnessed fall resulting in fractured hip. Patient outcome unknown. Two young patients going outside for a cigarette, one accompanied by staff. One patient decided to race down the stairs fell, and fractured ankle. Surgical Patient discharged the same day that mastectomy performed despite severe confusion, pain & erratic limb movements. Returned to ED with worsening symptoms. Determined to have suffered a stroke. PCH resident had unwitnessed fall resulting in fractured hip. Patient outcome unknown. Patient with known episodes of syncope had unwitnessed fall resulting in fractured ankle. Surgical Patient with known intracranial bleed awaiting surgery the following day.. Leapt out of chair when nurse left room, fell and fractured hip. Surgical Unknown Investigation into work of pathologist after routine audit prompted concerns. Physicians being contacted as discrepancies discovered. Unknown During surgery for fractured humerus, blood pressure & pulse difficult to detect on monitor. Successful resuscitation. Discharged a few days later. PCH resident tripped and found leaning against chair. Fractured hip. PCH resident had witnessed fall resulting in fractured hip. Surgical Patient had unwitnessed fall shortly after receiving 0.5 mg Ativan. Fractured hip. Surgical repair PCH resident had witnessed fall while reaching out to grab arm of chair. Fractured femur. PCH resident had unwitnessed fall from bed resulting in fractured hip. Surgical Patient with dementia noted to be missing from unit. Located on sidewalk outside hospital. Sent to ED where found to have fractured ribs and recurrent hemothorax. Died 2 weeks later.. PCH resident who wishes his independence had unwitnessed fall resulting in fractured hip. Surgical Patient on mental health unit had witnessed fall resulting in fractured hip. Surgical PCH resident fell when family member attempted patient transfer. Fractured nose. Fractured femur. Surgical repair of femur After surgery, condition deteriorated Died. PCH resident had unwitnessed fall resulting in fractured elbow. Replacement surgery PCH resident with cognitive impairment had unwitnessed fall resulting in fractured hip. PCH resident had witnessed fall resulting in fractured hip. EMS dispatched to patient with possible heart attack. Ambulance broke down en route to call. Second ambulance had to be dispatched. Patient died. Patient with history of falls at home had 2 falls in close succession resulting in fractured pelvis. Stable fracture managed with pain control and mobilization. Patient found without a pulse. Misidentification of the patient resulted in confusion concerning advanced care plan level wishes. Unsuccessful resuscitation. Inconsistent troponin results between 2 blood samples drawn on same patient at two different times. Received medication based on initial positive result. Discharged without adverse effects. Patient with cognitive impairment receiving rehabilitation had unwitnessed fall resulting in fractured hip. Surgical PCH resident drove off curb and flipped wheelchair, which landed on top of him. Fractured humerus.

10 Six day delay in receiving x-ray results. PCH resident with extensive history of falls had unwitnessed fall resulting in fractured hip. Surgical Patient with fever and hypokalemia. Ultrasound taken 3 weeks later showed clot in popliteal vein; anticoagulation started. PCH resident at high risk for falls had 2 falls over 2 week period. X-ray not done following either fall. Started on oral antibiotic for pneumonia. Died. Autopsy revealed 3 fractured ribs & pneumonia. Patient to ED with severe pain one week following back injury. Diagnosed with minor low back pain. Two days later, to second facility for urgent spinal surgery. Patient who ambulates independently with walker had unwitnessed fall resulting in fractured wrist. Surgical PCH resident with history of non-compliance had unwitnessed fall resulting in fractured hip. Surgical Patient independent in ambulation with cane had unwitnessed fall resulting in fractured humerus. Arm splinted, no surgery required. Unknown Patient received incorrectly matched unit of blood provided by Blood Bank. Had a transfusion reaction, but recovered with no long term adverse effects. Unknown A pathology review identified that there was a clinically significant change in the patient s original diagnosis. Unknown A pathology review identified that there was a clinically significant change in the patient s original diagnosis. Unknown A pathology review identified that there was a clinically significant change in the patient s original diagnosis. PCH resident had unwitnessed fall resulting in fractured hip. PCH resident slipped & fell while taking off socks. Fractured femur. PCH resident had unwitnessed fall resulting in intracranial bleed and fractured hip. Died. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident with a history of eating quickly choked on food resulting in partial airway obstruction. EMS called. Died 12 hours later in hospital. Femoral nerve injury during surgery for bowel obstruction. Previously mobile patient is now confined to wheelchair. PCH resident had unwitnessed fall resulting in intracranial bleed. Family decided on comfort care. Patient presented to ED with head injury 10 days prior. Diagnosed with intracranial bleed. Deteriorated and required admission/assessment at second facility.. Staff were getting PCH resident dressed prior to getting up out of bed. Was rolled on side away from staff and fell out of bed resulting in fractured knee. PCH resident had unwitnessed fall resulting in fractured hip. Surgical Following angiogram, patient was returned to rural site. Following discharge, patient collapsed Transferred via Lifeflight to Winnipeg and underwent surgery for internal bleeding. Patient had unwitnessed fall and was found lying face down on floor. Died the following day. PCH resident had unwitnessed fall while transferring without assistance resulting in fractured hip. Wearing socks but no appropriate footwear. Unknown Patient undergoing surgery to remove esophagus. Anastamosis created. Oral temperature probe inadvertently stapled into incision line. 1 cm of probe could not be removed. PCH resident with past history of falls had unwitnessed fall resulting in fractured hip. Surgical repair Had new seizures after return to PCH following surgery. PCH resident had unwitnessed fall resulting in hip fracture. Died. PCH resident forgot to use her walker and had unwitnessed fall resulting in fractured hip. Failure to recognize Acute Coronary Syndrome in ED associated with delay in diagnostics & intervention. Condition deteriorated. Admitted to ICU on intra-aortic balloon pump. Treatment plan consisted of chemotherapy followed by radiation therapy. Radiation therapy not completed as no order written. Mass in neck thought to be recurrent thyroid cancer. Several months later was found to be carcinosarcoma. This resulted in a significant change in prognosis for the patient.

11 Unknown To Operating Room with plan to exchange 7 year old implanted defibrillator. Incorrect serial number documented at time of insertion in another province. As a result, the replacement was not compatible. Procedure aborted and will require re-scheduling. PCH resident had unwitnessed fall striking head and fracturing hip. Condition following surgery deteriorated. Died. PCH resident had unwitnessed fall resulting in multiple fractures to their arm. Patient developed Stage 3 pressure ulcer on coccyx and right heel. 8 month old baby had repeated ED visits over 1 week. Each time, diagnosed with stomach flu, treated and discharged. One week later, when condition not improving, admitted to hospital. Two day later, deteriorated requiring admission to ICU. Had cardiac arrest and died. Incorrect medications dispensed for treatment of acute promyelocytic leukemia resulting in significant treatment delay. Admitted with intentional overdose of methadone. Treated and discharged the same day. The following day, was found deceased at home. Patient complaining of sore breast. Previous mammogram and ultrasound in No communication of results until At this time, the diagnosis of cancer was confirmed. Baby received expressed breast milk meant for another baby. Procedure for this activity not followed. Error discovered when nurse went to retrieve milk for another baby. Referred for urgent oncology consultation without definitive histological diagnosis, but most likely lung cancer. Died 2 days prior to appointment. PCH resident had unwitnessed fall resulting in fractured hip. Patient to ED with allergic reaction. Received epinephrine intravenously rather than intramuscularly as ordered. Developed cerebral hemmorhage. To ED following seizure. Found to have low serum calcium levels. Treated with intravenous Calcium Chloride. Patient complained of burning IV site. Sustained deep tissue chemical burn requiring skin grafting. Fistula needle for hemodialysis dislodged. Patient lost 1-2 litres of blood. Transported to ED for treatment. PCH resident with high risk for falls had been assisted onto commode by staff. Did not wait for staff assistance to return to bed. Fell and fractured hip. PCH resident who did not use her walker had unwitnessed fall resulting in fractured hip. Surgical Patient in isolation room had unwitnessed fall resulting in fractured hip. Patient to ED after multiple falls. Once admitted to hospital had unwitnessed fall. Issues with behaviour and physical aggression. CT scan shows intracranial bleed.. PCH resident who did not ask for assistance had unwitnessed fall resulting in fractured hip. Initially refused to go to hospital, then refused surgery. Emergent CT scan to rule out pulmonary embolism. Blood thinner had administered before any bleeding had been ruled out. CT scan showed thoracic artery dissection. Patient died in the Operating Room. PCH resident acquired a stage III & IV pressure ulcer. No pressure ulcer prevention guidelines in place. Pregnant female with twins believed to be 25 weeks gestation. To ED with abdominal pain, cramping, slight bleeding. Not assessed by obstetrics. Returned to ED the next day. Both babies died. Unknown A pathology review identified that there was a clinically significant change in the patient s original diagnosis. Unknown A pathology review identified that there was a clinically significant change in the patient s original diagnosis. PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident had unwitnessed fall resulting in fractured hip. Surgical PCH resident at high risk for falls had unwitnessed fall striking head. CT scan confirmed intracranial bleed. Family decided to provide comfort care. Died. Patient known to be at high risk for falls. Bed alarm sounded. When nurse entered the room, found patient standing at the foot of the bed and saw patient fall. Fractured hip.

12 Unknown Supervisory review noted that 2 incompatible (incorrect ABO) units of plasma were issued & subsequently transfused. Patient had no adverse effects as a result. Patient identified as high risk for falls had a fall witnessed by roommate resulting in fractured hip. Emergent cardiac catheterization. Condition deteriorated during procedure. X-ray equipment failed. Significant delay in moving to radiology suite to complete procedure. Patient s condition improved following event; no adverse effects. Patient had documented small coccyx wound in hospital. When assessed by Home Care Nurse, found to be unstageable pressure ulcer. PCH resident had unwitnessed fall resulting in fractured femur. Patient with multiple co-morbidities, immobility, low haemoglobin and high INR treated and discharged from hospital 9 days later despite shortness of breath and confusion. Returned to ED and died. Patient known to be high risk for falls had two falls one week apart in time. Nine days later, hip fracture found on abdominal X-ray. PCH resident on minced diet inadvertently given a sandwich & choked. Condition had deteriorated with possible recent stroke. Documentation on kitchenette kardex incomplete but complete on resident chart. Unable to clear airway, resident died. PCH resident has known documented allergy to mayonnaise. Following meal, complaining of difficulty swallowing. Tongue found to be swollen. To Emergency for treatment. PCH resident, with extensive history of falls, had unwitnessed fall, found wedged between wheelchair and heating vent. Fractured hip. PCH resident with history of stroke had unwitnessed fall resulting in fractured hip. Family decided on comfort care only. PCH resident with history of cancer had unwitnessed fall resulting in fractured ankle. Prior to beginning surgical procedure, a time out was not performed to verify that all details regarding surgical procedure were correct. Surgery began on the wrong leg. Error discovered and correct leg was operated on. PCH resident had unwitnessed fall resulting in fractured hip. Patient outcome unknown. On arrival of EMS, patient found to be in cardiac arrest. Two attempts to defibrillate the patient. Patient died. Difficulty establishing intravenous access prior to surgery. Tourniquet left on arm during procedure. Arm swollen, cold & blue in color. indicating possible nerve damage. Patient with significant risk factors for skin breakdown found to have developed unstageable pressure ulcer to heel. PCH resident had acute change in condition. EMS called. Ambulance did not arrive for one hour following call. Found to be pale, diaphoretic and having difficulty breathing on arrival to ED. Family of patient with cancer receiving end of life care believes that patient was given an overdose of Hydromorphone that resulted in death. Felt that resuscitation attempts should have been made. Issue with communication regarding the nature of illness. Patient in busy ED received medications not prescribed for her. Oxygen saturation levels and respiratory rate dropped. This resulted in an extension of her expected hospital stay. Patient with significant risk for skin breakdown developed unstageable pressure ulcer on coccyx. Patient fell the day that discharge from hospital was to occur. Required transfer for surgery. Patient had disease which resulted in weakened bones. Patient who had hip replacement surgery 12 days earlier had an unwitnessed fall. Hip replacement hardware displaced requiring second surgery. Patient receiving high doses of Hydromorphone at frequent intervals. Dosing increased too quickly. Lapse in required assessment occurred. Patient required treatment as respiratory rate dropped too low. Hospital stay extended for further observation. Neonate given ten times the prescribed dose of morphine. Ten hours later, developed cyanosis and swelling of eyes, hands and feet requiring antidote administration. Nursing staff heard chair alarm activate after PCH resident removed seatbelt and got up without assistance. Found resident had fallen in another resident s room resulting in fractured hip. PCH resident developed Stage 3 pressure ulcer. No pressure ulcer prevention plan in place.

13 Patient at high risk of falls had unwitnessed fall resulting in intracranial bleed. Admitted to ICU. Resident with history of unsteady gait, poor vision and wandering behavior had unwitnessed fall resulting in fractured hip and dislocated shoulder. Skin tears on patient s hip evolved to unstageable pressure ulcer to hip and coccyx. High risk for skin breakdown given medical history and risk factors. During surgery to remove gall bladder, portal vein inadvertently tied off. Patient developed liver failure. Assessment for possible liver transplant. Discharged from hospital. Following surgery for fractured patella, patient told that a brace was not required to be worn. Subsequent re-fracture and bone infection. Patella was removed. Patient has decreased mobility. PCH resident at high risk for falls and with previous fall history had witnessed fall resulting in fractured hip. PCH resident receiving oxygen therapy had unwitnessed fall resulting in fractured hip. Surgical repair PCH resident had unwitnessed fall resulting in fractured hip. Patient treated in ED following falls in the community. On discharge, it was noted that patient was not able to walk. Examination indicated collapsed lung & spinal injury. Died. Patient had unwitnessed fall. Staff alerted when bed alarm sounded. Fractured hip. Underwent coronary angiogram & angioplasty. Nine months later, CT scan confirmed the presence of a thrombus associated with lost guide wire used in procedure. Delay in administration of Duratocin following C-section. Patient had post-partum haemorrhage contributing to an extended hospital stay. Patient who required standby assistance from staff for ambulation had unwitnessed fall resulting in fractured hip. Surgical PCH resident had unwitnessed fall resulting in fractured hip. Outcome unknown. PCH resident had unwitnessed fall resulting in fractured hip. Outcome unknown. While sitting up, patient fell forward striking head. Intracranial bleed. To ED with complaints of severe neck & shoulder pain. Atypical presentation. Discharged with medication and instructions. To second ED days later with increasing symptoms. MRI performed. Spinal injury. Patient will have permanent paralysis. Patient with CVA & hemiparesis. High risk for pressure ulcer development. Following 3 month hospitalization, developed deep vein thrombosis and unstageable pressure ulcer to hip. PCH resident had unwitnessed fall resulting in fractured hip. Outcome unknown. PCH resident had unwitnessed fall resulting in fractured hip. Few fall prevention interventions. One week following below-knee amputation, unstageable pressure ulcer detected at operative site. Absence of a pressure ulcer prevention plan. PCH resident had unwitnessed fall resulting in fractured hip. Outcome unknown. Tonsil biopsy specimen not transported in timely fashion to Lab as in specialized protocol. Unable to complete requested testing. Patient will require a second biopsy to obtain tissue for analysis. PCH resident had unwitnessed fall resulting in fractured hip. Outcome unknown. PCH resident had witnessed fall resulting in fractured hip. Outcome unknown. Following inguinal hernia repair, hernia still visibly present. Second surgery required to repair ventral hernia. Initial surgery may not have been needed. Patient in ED went outside for a cigarette while attached to an oxygen tank. Burns to face & neck. Required intubation and observation to ensure that complete airway obstruction did occur. PCH resident had witnessed fall resulting in the need for hip replacement surgery. Five months following diagnosis of adenocarcinoma of the colon, it was recognized that no referral to Medical Oncology had occurred. Patient died in the interim. PCH resident with dementia had unwitnessed fall resulting in fractured hip. Surgical PCH resident had unwitnessed fall resulting in fractured femur. Outcome unknown. Legally blind PCH resident fell while ambulating resulting in fractured hip. Outcome unknown. Patient being treated for complications of diabetes & pneumonia. Following discharge, haemorrhage noted behind eyes. Macular edema requiring surgery. Miscommunication regarding location of patient associated with delay in EMS response time. Retained surgical gauze in surgical wound delayed healing. No formal wound management protocols