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.

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 regional health authorities, hospitals, personal care homes, all licensed, land and air ambulances, the Selkirk Mental Health Centre, Cancer Care Manitoba and Diagnostic Services Manitoba.

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 to identify possible system changes. 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.