- Resource Centre
REGINA, SK., June 8, 2021
In her 2021 Report – Volume 1, Chapter 6, Provincial Auditor Judy Ferguson reports the need for the Ministry of Health to better utilize reporting of critical health incidents as a tool to improve patient safety. A critical incident is a serious adverse health event that did or could have resulted in serious harm or death of a patient.
The Ministry is charged with overseeing mandatory reporting of critical incidents, evaluating the likelihood of identified corrective actions will prevent recurrence of future incidents, and helping address system-wide concerns affecting patient safety.
The audit found the Ministry does not determine whether it is notified of all critical incidents. Audit analysis suggests underreporting of incidents. For example, between December 2019 and September 2020, the Saskatchewan Health Authority reported to the Ministry 17 critical incidents related to medical devices whereas, for the same period, it reported 24 incidents for medical device failures to Health Canada.
The audit found the overall number and types of reported critical health incidents are not trending downwards in Saskatchewan, with mainly the Authority reporting over 200 critical incidents in each of the last two years. Also, in 91 reported critical incidents in 2019-20, a patient died.
As well, the audit found the Ministry did not encourage prompt critical incident reporting. The Authority often submitted to the Ministry critical incident notifications and reports late. On average, the Authority took over 100 days to report. Delayed reports result in delays in the Ministry evaluating the robustness of Authority-planned corrective actions, which delays properly addressing contributing factors.
Also, the Ministry does not monitor whether the Authority addressed the identified causes of reported critical incidents. The audit found over two-thirds of corrective actions were reported as not implemented by the Authority. Sufficient actions should reduce, over time, the degree of injury and the kinds of critical incidents that occur in specific facilities. Ferguson notes, “Not knowing whether corrective actions are taken increases the likelihood of recurring patient harm or death.”
Furthermore, the Ministry does limited analysis to identify whether system-wide improvements are needed to keep patients safe. While the Ministry periodically issued patient safety alerts, very few of those issued in the last three years related to the highest subcategories of critical incidents reported (e.g., medication errors). Patient safety alerts are to communicate patient safety information for the benefit of the broader healthcare system.
Research suggests about one-third of critical health incidents in hospitals are preventable. Ferguson reports, “If used well, reporting of critical incidents can be an effective tool in improving patient safety.”
The Office of the Provincial Auditor is an independent office of the Legislative Assembly of Saskatchewan. The Office serves the Members of the Legislative Assembly and the people of Saskatchewan by providing independent assurance and advice on the management, governance, and effective use of public resources.
For more information, please contact:
Judy Ferguson, FCPA, FCA
Provincial Auditor of Saskatchewan
1500-1920 Broad Street
Regina, Saskatchewan S4P 3V2
Additional issues highlighted in the Provincial Auditor’s 2021 Report–Volume 1 include:
See accompanying news releases and backgrounders for further details about key topics.
Download News Release: 2021 Report Volume 1 - Early Learners read more
Download News Release: 2021 Report Volume 1 - Critical Incidents read more
Download News Release: 2021 - Report Volume 1 - Backgrounder read more
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