Critical Incidents Reported to Manitoba Health April 1, 2013 - June 30, 2013 Degree of PCH resident had unwitnessed fall resulting in fractured hip. Found on floor with walker by feet. Surgical repair PCH resident rolled over and fell out of bed. Put self back to bed without assistance. Fractured hip. Surgical repair declined. Patient developed unstageable pressure ulcers to both heels. Patient stood up and felt off balance. Nurse helped ease the patient to the floor. Fractured ankle. PCH resident had unwitnessed fall resulting in fractured hip. Found sitting on floor beside bed. Surgical repair Peripherally inserted central catheter inserted for long term IV treatment of pneumonia. Continued symptoms despite treatment. CT scan shows foreign body in pulmonary artery. Radiological intervention needed for removal. Patient with deep vein thrombosis on bedrest without anticoagulation therapy. Twelve days later, to Emergency Department (ED) in cardiac arrest. Died. Patient who was receiving antibiotics had drop in serum sodium levels. Antibiotic treatment unchanged despite advice to do so. When antibiotics finished, serum sodium level returned to normal. Patient presented to ED with abdominal pain following a blow to abdomen while playing soccer. Discharged. Two days later, symptoms worsening & unresponsive. Cardiac arrest. Resuscitation unsuccessful. PCH resident had unwitnessed fall resulting in fractured hip. Found lying on the floor face down. Fractured hip. Surgical repair Patient having surgery to eye muscles. Correct eye identified before surgery and 'time out' done correctly. Surgery performed on the wrong eye. Surgery performed on the correct eye as well Patient had unwitnessed fall resulting in fractured femur. Surgical repair PCH resident had witnessed fall resulting in fractured hip. Surgical repair Patient had unwitnessed fall resulting in fractured hip. Surgical repair Patient had witnessed fall while walking with family member. Fractured hip. Surgical repair Patient s Stage 2 pressure ulcer on sacrum deteriorated to Stage 3 during hospitalization. PCH resident had reddened area on heel. One week later, this area deteriorated to Stage 3 pressure ulcer. Patient had cardiac arrest after receiving anesthesia in preparation for surgery. Successful resuscitation. Transferred to second facility where the patient had a second cardiac arrest. Died. PCH resident fell. Initial X-ray showed no fracture. For next week, resident continued to complain of pain. Repeat X-ray shows fractured hip. Surgical repair Infant was fed incorrect mother's breast milk. Safety check procedure not followed. PCH resident, legally blind, tripped on the corner of a chair and fell to the ground. Fractured hip. Surgical repair PCH resident slipped and fell while walking with daughter. Though wearing hip protectors, hip was fractured. Acutely ill at the time of fall. Surgical repair Patient had witnessed fall in hallway when attempted to get up from wheelchair. Fractured hip. Surgical repair Patient had unwitnessed fall resulting in fractured hip. Surgical repair Patient developed Stage 3 pressure ulcer to coccyx. Infant received ten times the ordered dose of medication that blocks insulin secretion. Medication was intended for another patient. Supportive treatment. Recovered. PCH resident developed unstageable pressure ulcer to buttock. 1
PCH resident had unwitnessed fall. Found kneeling on floor in room. Fractured hip. Surgical repair PCH resident's Stage 2 pressure ulcer to buttock deteriorated to Stage 3 pressure ulcer. Patient's upper arm fractured during 3 day hospitalization. No known mechanism of injury. No past medical history available. Patient developed Stage 3 pressure ulcer to coccyx. PCH resident was physically assaulted by co-resident. Family declined examination by ED physician following assault. Condition deteriorated. Died four days later. PCH resident developed unstageable pressure ulcer to coccyx. PCH resident had unwitnessed fall onto floor beside bed. Fractured hip. Surgical repair Patient had unwitnessed fall. Lost footing and fell in washroom striking head. Intracranial bleed. Surgical intervention to control bleeding. PCH resident had unwitnessed fall when their legs buckled. Fractured elbow. Surgical repair PCH resident had unwitnessed fall resulting in fractured femur. Surgical repair Patient with known diagnosis of cancer had multiple falls after outpatient blood transfusion. Refused help when offered. Intracranial bleed with poor prognosis. Died. Patient returned to the unit following Nuclear Medicine testing without vital signs. Resuscitation attempts unsuccessful. PCH resident developed deep tissue injury to heel. Felt to be related to crossing legs when in bed. Patient had unwitnessed fall resulting in fractured hip. Roommate notified staff of patient fall. Surgical repair Patient had blisters on both heels. Right heel blister deteriorated to unstageable pressure ulcer. Patient with early squamous cell carcinoma was referred to Cancer Care Manitoba. CT scan ordered. Three month delay in interpretation. Required second radical surgery. Woman in labor inadvertently received seven liters intravenous fluid. After discharge from hospital, returned to ED with shortness of breath and high blood pressure. Required admission for treatment of pleural effusions. PCH resident had unwitnessed fall resulting in fractured ankle. Surgical repair Patient had unwitnessed fall while transferring to bed. Hip re-fractured. Patient developed septic shock after surgery. Sent to another hospital for emergent CT scan. Returned without physician assessment. Cardiac arrest. To ICU. Died. Patient transferred in unstable condition to second site with high levels of supportive oxygen. Required ICU admission. Marked progression in size of lung lesion during six week wait for surgery. Surgery commenced but aborted due to the extent of disease. PCH resident's deep tissue injury to hip deteriorated to unstageable pressure ulcer. PCH resident had unwitnessed fall resulting in fractured hip. Chair alarm malfunctioned. Surgical repair Immobile PCH resident developed unstageable pressure ulcer to foot. PCH resident had unwitnessed fall resulting in fractured hip. Patient declined surgery. Patient had complex surgical revision of knee/hip performed with some loaner equipment & implants. Procedure will need to be redone at later date. Patient had unwitnessed fall from bed over siderails. Was trying to reach object on bedside table at the time. Fractured ankle. Surgical repair Patient to ED with obvious symptoms of stroke. No physician assessment for 5.5 hours. Missed window of opportunity for thrombolysis. 2
Patient living with chronic mental health issues. Known to be non-compliant with medication. Had a seizure in ED. Not medically cleared prior to transfer to psychiatry. Had a second seizure. Admitted to ICU. Patient developed unstageable pressure ulcer to coccyx. Patient had unwitnessed fall resulting in fractured hip. Found lying on hallway floor. Surgical repair Grossly elevated blood glucose levels. Hypoglycemic medications and blood sugar monitoring discontinued two to four weeks earlier. Patient underwent bilateral lumpectomy. Transposition of margin status. More tissue taken from right breast, not enough tissue from left breast. Additional surgery was required. Patient had unwitnessed fall from bed during the night. Found on floor. Fractured hip. Conservative, non-surgical treatment provided. Patient developed unstageable pressure ulcer during hospitalization. Resident had witnessed fall from wheelchair and struck head. Unresponsive. To ED for assessment and treatment. PCH resident had unwitnessed fall during the night. Fell when transferring from chair to bed. Fractured hip. Surgical repair Patient received short acting formulation of drug to slow heart rate rather than the slow release formulation. Developed bradydysrhythmias. Transferred to ICU for monitoring. Mom and newborn on post partum unit. Three days later, baby sent to Intermediate Nursery severely dehydrated, hypoglycemic & lethargic. Elderly patient with congestive heart failure. Concerns regarding medical monitoring. Physical deterioration requiring ICU admission. Developmentally delayed patient with spinal cord injury. Non-compliant with turning and positioning schedule. Developed Stage 3 pressure ulcer to coccyx. Patient with wandering behaviour. Was very tired, tripped and fell in hallway. Fractured hip. Patient with history of confusion & aggression had witnessed fall. Lost balance when turning. Fractured hip. Surgical repair PCH resident receiving end of life care had unwitnessed fall in their room. States that they slid off the bed. Hip was fractured second time. PCH resident with metastatic breast cancer developed unstageable pressure ulcer to coccyx. PCH resident had unwitnessed fall resulting in fractured elbow. Bed alarm sounded. Found on floor near bed. Baby was delivered without signs of life. Cardiopulmonary resuscitation attempts unsuccessful. PCH resident had witnessed fall when she stood up from wheelchair. Fractured hip. Surgical repair PCH resident had unwitnessed fall. Did not use walker when ambulating. Initially verbally responsive then lost consciousness. To ED for assessment and treatment. Transferred back to PCH for comfort care. PCH resident had unwitnessed fall in hallway resulting in fractured hip. Surgical repair Patient developed unstageable pressure ulcer to coccyx. PCH resident had unwitnessed fall in their room resulting in fractured hip. Surgical repair PCH resident with impaired vision attempted to get up from wheelchair and had a witnessed fall. Fractured hip. Surgical repair Patient, at high risk for falls, had unwitnessed fall. Found on the floor by staff. Fractured hip. Surgical repair 3
Patient had witnessed fall resulting in fractured hip. Stood up out of chair and fell onto right side. Hemoglobin dropped. Died 8 hours later. Patient had two unwitnessed falls during the night. Later developed bleeding from the bowel. Blood pressure and hemoglobin dropped. Died 8 hours later. Patient admitted with no identified fractures. Fifteen days later, found to have fractures to ribs and pelvis on bone scan. PCH resident developed Stage 3 pressure ulcer to hip. PCH resident found sitting on floor beside bed. Fractured hip. Surgical repair Documented allergy to Penicillin. Received Amoxicillin. Developed difficulty breathing. Received epinephrine twice. Further deterioration in condition. To ED for further treatment. PCH resident fell twice in one day, the first fall witnessed, the second fall unwitnessed. After second fall, lethargic, slow to respond. To ED for assessment. Died 6 hours later. Patient experienced emotional distress during induction phase of anesthesia prior to surgery. Discharged home 24 hours later. Patient presented to Nursing Station three times in three days with similar complaints. Each time, phone consultation with physician in regional hospital. Died 4 hours after third visit to Nursing Station. Patient developed unstageable pressure ulcers to coccyx and heels. PCH resident had Stage 2 pressure ulcer at time of transfer to hospital. Returned to PCH with unstageable pressure ulcer. Patient had unwitnessed fall resulting in fractured hip. Surgical repair PCH resident, at high risk for wandering and exit seeking behaviour, was found outside the facility. Resident had had multiple witnessed falls. Fractured hip. Surgical repair PCH resident with an unsteady gait had unwitnessed fall. Was found on the floor in the hallway. Fractured hip. Surgical repair Patient s endotracheal tube displaced during ambulance transfer. Hypoxia led to cardiac arrest and brain injury. PCH resident's Stage 2 pressure ulcer deteriorated to Stage 3 ulcer despite ongoing treatment. Chronic issues with skin breakdown. PCH resident developed Stage 3 pressure ulcer to coccyx despite ongoing treatment. PCH resident had unwitnessed fall. Apparently tripped over telephone cord. Found lying on floor in room. Fractured hip, wrist and finger. Patient had unwitnessed fall that resulted in oxygen tubing becoming disconnected. Found on floor by the bed. Fractured hip and humerus. PCH resident tripped while walking with spouse. Fractured hip. Surgical repair PCH resident developed unstageable pressure ulcer to hip. PCH resident developed Stage 3 pressure ulcer to coccyx. Home Care client developed Stage 3 pressure ulcer to sacrum. Patient fell while trying to get out of bed. Fractured hip. Surgical repair Patient received a greater dose of radiation to the prescribed treatment area than ordered by the physician. Radiation was discontinued. Frequent assessment required. PCH resident bumped into co-resident. Both residents fell. Fractured pelvis. Resident s behaviour was more agitated during the shift prior to incident. PCH resident had unwitnessed fall resulting in fractured hip. Found sitting beside bed. Surgical repair PCH resident had unwitnessed fall. Lost footing while walking. Found sitting at foot of bed. Fractured hip. Surgical repair Patient received an overdose of medication, a beta blocker. Bradycardia & cardiac arrest. Supportive treatment and ICU admission. 4
Error in the release of tissue to funeral home. Family waiting at the grave site when error noticed by funeral home director. PCH resident was being transferred from wheelchair using a mechanical patient lift. Resident fell out of sling and hit their head. Laceration to head required suturing. Patient presented to ED with painful vaginal bleeding. Pregnancy test positive. Ultrasound ordered in ED was not completed until 5 days later as an outpatient. Ectopic pregnancy found. Surgery performed. 5