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The provincial auditor says the Ministry of Health needs to do a better job of using critical incident reporting to improve patient safety in healthcare facilities.
That was one of provincial auditor Judy Ferguson’s top findings in this year’s auditor report.
A critical incident is described in the report as a “serious adverse health event” that occurred in a healthcare facility and resulted in serious harm to a patient or death, or had the potential to. It can include a medication error, self-harm or suicide, death or injury from a fall or acquired pressure ulcers, among other health events.
The law requires the healthcare organizations – like the Saskatchewan Health Authority (SHA) – to report critical incidents to the Ministry of Health.
Ferguson said effective use of the reporting should result in a decrease in the overall number and seriousness of critical incidents. However, according to the report, the number of critical incidents reported in the province is not going down.
In 2019-20, there were 290 critical incidents reported to the Ministry of Health. This was the highest number in the past five years and an increase from 221 in 2018-19.
The auditor examined the Ministry of Health’s processes for using critical incident reporting to improve patient safety and identified a number of areas of improvement.
UNDERREPORTING OF CRITICAL INCIDENTS
Ferguson found the Ministry of Health doesn’t have a way to track if it gets reports for all critical incidents and the data suggests an underreporting of critical incidents to the ministry.
Healthcare organizations like the SHA are required to track and report a number of adverse events and critical incidents to Health Canada and various other bodies.
The auditor said the data shows a gap between the number of adverse events tracked and reported to various regulatory bodies and the number of critical incidents that were reported to the ministry.
For example, the SHA reported 24 medical device failures to Health Canada, but the auditor said it only reported 17 medical device critical incidents to the ministry in the same timeframe.
The auditor suggested the ministry analyze other health data available to ensure all critical incidents are reported.
INCOMPLETE REPORTING AND LATE NOTIFICATION
The audit found the Ministry of Health does not always obtain information that is missing from critical incident forms or confirm the critical incident form is properly filled out.
Ferguson’s analysis found 12 per cent of the reports submitted between April 2019 and September 2020 did not have the location field filled out, which means the form did not indicate if the incident took place in a long-term care home, hospital or other healthcare facility.
The auditor also determined 26 per cent of incidents reported between April 2019 and September 2020 did not include the region aware date – which is the date the SHA determined an event to be a critical incident.
Without having the date of the critical incident, Ferguson said the ministry cannot monitor if it’s notified of critical incidents within three business days, as required by the law.
The auditor found the ministry receives over 30 percent of initial notifications of critical incidents later than the three days.
Ferguson recommended the ministry obtain missing information and follow up when reporting deadlines have passed.
MINISTRY UNSURE IF CORRECTIVE ACTIONS ARE IMPLEMENTED
The auditor said the ministry does not know whether the SHA addresses the causes of critical incidents that were reported and does not track the progress of corrective actions.
In the analysis of 21 critical incident reports, Ferguson found 68 per cent of corrective actions were reported as not implemented by the SHA.
The report said the Ministry of Health believes healthcare organizations like the SHA are “solely responsible” for implementing corrective actions and it does not require the SHA to routinely give updates on the status of any corrective actions.
Ferguson said the ministry should start monitoring the status of planned corrective actions stated in critical incident reports.
GOVERNMENT AND OPPOSITION REACTION
The Opposition NDP said the government needs to implement the auditor’s recommendations to make sure critical incidents are tracked and fixed.
“It’s incredibly concerning to hear that critical incidents aren’t being reported properly, aren’t going down, and aren’t being followed up on,” said NDP health critic Vicki Mowat in a press release.
“When something goes terribly wrong for patients in our healthcare system, it needs to be documented and fixed so that it doesn’t happen again.”
SHA CEO Scott Livingstone said the health authority is working with the ministry and other partners to find ways to expedite the auditor’s recommendations.
“We are looking at many options including electronic systems that would allow us not just to report critical incidents in a timely way, but also track those near misses so those incidents that don’t cause a critical incident or harm to patients…are learning events,” said Livingstone.
Health Minister Paul Merriman thanked Ferguson and her team for their work and said the government has accepted the recommendations put forward.
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DEAD FISH HANDSHAKE
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