Infant received 10 times more morphine than normal

An infant in St. Boniface Hospital’s neonatal intensive care unit was given 10 times the normal dose of morphine — that's just one critical incident case uncovered by the CBC News I-Team through a freedom of information request.

“It can be potentially very serious. It can be fatal. Morphine depresses the respiratory drive in the brain. That can lead to a baby stopping breathing,” said  patient safety expert Dr. Rob Robson, an adviser at Healthcare System Safety and Accountability.

The infant started started having apnea spells, needed to be intubated and was put on a ventilator, according to the critical incident disclosure record. The infant’s condition was noted as stable four days after the incident.

The error occurred in October 2014. The record says the in-house neonatal physician had ordered the morphine.

Robson says incidents that only involve a single person are rare; the majority of cases involve multiple factors.

“It can be as simple as the initial order being written in a way that it couldn't easily be read, but there are a wide variety of system-related issues which can also contribute to this kind of error,” he said.

A similar case involving an infant was documented in a learning summary in 2008. Learning summaries are produced by the Winnipeg Regional Health Authority (WRHA) after a critical incident. They are distributed to staff and posted on the WRHA’s website with the goal of preventing future mishaps.

In the case that was reported in 2008, a baby received twice the normal dose of dopamine, a drug administered to treat respiratory distress, while it was being resuscitated.

The learning summary notes the error happened less than two weeks after the pediatric emergency services were moved to a new area and staff were not yet familiar with the location of supplies.

In addition, the dopamine was a non-standard concentration, according to the learning summary. Plus, the labels on the different concentrations of the drug were virtually identical. It was also noted that decision aids for drug dosing were not available.

No harm to the infant was apparent but “the possibility of subtle damage cannot be conclusively ruled out,” the summary said.

Medication errors go unreported

Seven per cent of percent of critical incidents were linked to medication issues in WRHA hospitals from April 2007 to March 2012 — far fewer than is to be expected, according to numerous studies.

“Medication-related critical incidents, we know from studies in Canada and from 11 international studies, comprise about 25 per cent of the total number of critical incidents. So, it's a relatively common problem,” said Robson.

The reports obtained by CBC News described other medication errors, including a patient who died after going through withdrawal, which led to severe seizures and cardiac arrest.

In 2013, a patient was administered the wrong medications and suffered  cardiopulmonary arrest. That same year, a patient ended up intubated and on a ventilator after getting the wrong medications.

Victims of medication error react

Marlene Kollinger was upset to hear about about the infant’s medication error.

“It scares the heck out of me,” she said.

Her husband, Karl Kollinger, feels lucky to be alive after he was given the antibiotics intended for his roommate after cancer surgery in 2014. In the end, he suffered no harm and no critical incident was filed.

“My trust is totally gone,” said Marlene Kollinger.

“I advocate that anyone who has a patient in hospital be alert, be aware and ask questions — Who is it for? What is it for? — and ask to look at the medication bag.”

Karl Kollinger is now watching all medications given to his wife, who just finished breast cancer treatment.

“At the beginning, I thought the health care was great. But now I am skeptical,” he said. “I watch, we both watch.”

Marlene Kollinger said she would like to see serious repercussions for the people who make the errors.

“The main thing is accountability. If these people who we have hired as professionals are made accountable for their actions, they will take that extra second,” she said.

Kollinger said she would like to see concrete punitive measures, like financial penalties or even firing.

Reporting of incidents on the decline

Fear of punishment is one of the reasons why medical professionals do not report critical incidents, explained Robson.

“In many facilities, staff still don't have confidence that if they report, or if they're involved, that it won't be used as a kind of punitive thing against them and that there won't be some sort of consequences directly as a result of their reporting something,” Robson said.

Robson said the WRHA used to be a leader in reporting critical incidents, with a rate of 25 to 30 per cent of expected incidents being disclosed. However, recent statistics show reporting is on the decline.

WRHA acute care hospital incident reporting peaked in 2009-10 with 249 incidents. That figure was nearly cut in half in 2013-14, a number Robson says represents approximately 10 percent of all cases.

(Source: Winnipeg Regional Health Authority)

“That’s disappointing. Usually what it reflects is the culture going back to a time when people are not comfortable raising issues,” he said.

Low rates of reporting critical incidents may prevent safety improvements, he added.

“I think it's predictable that the learning will decrease and therefore the useful changes that might be suggested will decrease,” said Robson.

“I think it's an absolute scandal that these incidents are occurring and the information is not being shared with staff, or with the public, or with the media.”

The WRHA declined an interview but in an email said it follows the laws pertaining to critical incident reporting and shares critical incident information on its website.

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