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Medical error

Patient safety initiatives announced in Manitoba

WINNIPEG – Annual patient-safety reports, analysis and learning sessions for staff, quarterly critical incident summaries and a new website are among the new tools being introduced as the next steps in Manitoba’s strategy to reduce errors in the healthcare system and foster a culture of openness and transparency among health professionals.

“Manitoba’s steps in patient safety show a commitment to transparency, humility of leaders and the acknowledgement the system is imperfect,” said Hugh MacLeod (pictured), chief executive officer of the Canadian Patient Safety Institute. “This honesty positions Manitoba as a leader in Canada and will set the stage for a transformation in patient safety.”

The first annual patient safety report, Patient Safety in Manitoba 2007 to 2010, was released earlier this month. The report shows that Manitoba’s mandatory, no-blame critical-incident reporting legislation has increased the number of incidents being reported and the opportunity to learn from and prevent the recurrence of errors that do take place.

“Patients and families expect the healthcare system to investigate when errors happen and to make changes to prevent them from happening again,” said Health Minister Theresa Oswald. “Patient safety is a priority for Manitoba’s healthcare system. The new steps introduced today not only support making the system safer, but also improve transparency so that Manitobans can see how acknowledging errors that occur in healthcare improves patient safety.”

Reporting critical incidents became mandatory in Manitoba on Nov. 1, 2006. This was done to help hospitals, facilities, regional health authorities (RHAs) and provincial organizations in learning from critical incidents when they happen, said Oswald. The province is now analyzing reported incidents to identify trends across the province that will further improve patient safety.

“Reporting and investigating critical incidents is foundational to improving patient safety,” said Laurie Thompson, executive director of the Manitoba Institute for Patient Safety (MIPS). “More of the critical incidents that occur are being reported and that means more opportunities to improve the healthcare system and to make it safer for patients.”

The minister also noted the province has launched a new website that includes information for the public on what to do if someone has a patient safety concern and how the province is improving patient safety. The new annual report and other patient safety information is now available on the website at

Starting next year, Manitoba Health and MIPS will co-host a patient safety learning day to bring together patient safety investigators from the Regional Health Authorities, quality-improvement staff, doctors, nurses, pharmacists and the understanding they have gained from their patients.

They will review trends in critical incidents and other quality issues. The goal of these sessions will be to identify actions to address these issues. Increased trend analysis of investigation results will result in opportunities for more learning and improvement across all of the regional health authorities in Manitoba.

Interest in patient safety grew in Manitoba after the discovery of 12 potentially preventable infant deaths in 1991 at the pediatric cardiac surgery program at the Health Sciences Centre in Winnipeg. An inquest report was released in 2000 followed by the establishment of an implementation committee led by Prof. Paul Thomas.

In total, 53 recommendations to improve patient safety were made. All recommendations have been put in place, including a system to learn from errors, now reported as critical incidents. In 2004, the Manitoba Institute for Patient Safety was created. In 2006, legislation was introduced for mandatory no-blame reporting of critical incidents.

As part of the process to increase public transparency, a summary of critical incidents reported to Manitoba Health will be issued on a quarterly basis starting in 2011. Should any major gaps that require immediate attention be identified through critical incident reporting, the province will issue patient safety alerts to RHAs and provincial organizations to ensure a rapid response across the province, said Oswald.

Posted November 18, 2010