Critical Incident Reporting and Investigation
In 2006, Manitoba introduced mandatory no-blame critical incident reporting across the health system to support a culture of learning and openness. Critical incidents are not reported to lay blame on individuals. The purpose of reporting is to look at what can be done differently and what improvements can be made to the way health care providers work. This process does not replace other disciplinary investigations such as reviews by employers, complaints to professional regulatory bodies or civil law suits. Instead, investigating critical incidents complements these processes.
What is a Critical Incident?
Manitoba’s legislation defines a critical incident as “an unintended event that occurs when health services are provided to an individual and results in a consequence to him or her that is serious and undesired.” This can include death, injury and disability, and “does not result from the individual’s underlying health condition or from a risk inherent in providing the health services.” The legislation applies to all Manitoba’s health authorities (regional health authorities, Shared Health, Cancer Care Manitoba), hospitals, personal care homes, licensed land and air ambulances, and the Selkirk Mental Health Centre.
To encourage reporting and full, open participation in the investigation by health care providers, some parts of the investigation process, including opinions, speculations and advice, are confidential and privileged under law. This is intended to support providers and encourage them to speak frankly and openly about what occurred. This approach is used in several jurisdictions around the world.
Once a critical incident is reported, an investigation takes place to determine the facts of the situation and make recommendations for improvements to reduce the chances of the error happening again. The critical incident legislation also requires disclosure to the patient and/or family that an incident occurred, the facts about what happened and what is being done to address it. As part of the investigation, recommendations for improvements are made to reduce the chances of the error happening again.
