Patient Safety Learning Advisories (PSLAs)

Critical incidents and other patient safety events are reviewed to identify ways in which the health care system might change so that health care delivery can be made safer.

All regional health authorities and provincial organizations are required to share the “lessons learned” from these events as applicable. This learning may be the result of the review of one event or a number of similar events.

Manitoba Health (Health) began posting these patient safety learning advisories in November 2014, so they can be shared with a larger public audience.

These patient safety learning advisories are linked to the Canadian Patient Safety Institute (CPSI) Global Patient Safety Alerts (GPSA). This will allow for the learning from these events to be shared nationally and internationally.

All reports are in Adobe AcrobatPDFformat, and currently available in English only.

  1. Failure to Communicate Diagnostic Investigation Findings
  2. Aggregate Analysis of Stage 3 and 4 Pressure Ulcers
  3. Resident and Co-Resident Aggression
  4. Failure to diagnose serious malignancy
  5. Inadvertent Administration of Neuromuscular Blocking Agent during Procedure
  6. Pressure Injury Related to Use of Traction Equipment
  7. Failure to recognize perforated viscus following surgery
  8. Abscess Related to Insect Bite
  9. Choking in a Personal Care Home Resident
  10. Discharge Instructions in the Emergency Department
  11. Error Related to Lithium Dosage Conversion
  12. Fall from Bed with Serious Injury
  13. Cancer Diagnosis Communication to Patient
  14. Discrepancy between Pathology Specimens on Two Occasions
  15. Specimen Referred for Testing Out of Province
  16. Transporting Specimen for External Consultation
  17. IV Insertion Prior to Radiology Examination
  18. Discrepancy in Diagnosis Based on Biopsy Results
  19. Delay in Receiving Laboratory Test Results
  20. Pressure Ulcer
  21. Retention of a foreign body in a patient after surgery
  22. Delay in Treatment
  23. Pressure Ulcer
  24. Communication and Documentation of Allergies
  25. Development of a Pressure Ulcer in a Hospitalized Patient
  26. Communication of Biopsy Results & Treatment Delays
  27. Fall from Radiation Treatment Table
  28. Melanoma Misdiagnosis
  29. The Role of Automatic Doors in Patient Fall
  30. Improper Footwear results in Changes to Falls Prevention Management
  31. Sling Loop Migration Contributes to Fall from Client Lift
  32. Aggressive Client Behaviour Contributes to Client Harm
  33. Development of a Pressure Ulcer in a Hospitalized Patient
  34. Hip Fracture Related to a Patient Fall
  35. Delay in Treatment
  36. Neonatal Death
  37. Neonatal Death
  38. Deteriorating Patient Condition Associated with Medical Gas System Dysfunction
  39. Failure to Provide High Flow Oxygen during Intra-facility Transfer
  40. Post Endoscopy Complications To Reduce Gastric Volvulus
  41. Delay in Treatment Referral for Pulseless Limb
  42. Deterioration in Patient Condition Related to Incorrect Kaofeed Tube Placement
  1. Burn Injury During Removal of a Fibreglass Cast
  2. Stage 3-4 Pressure Injuries in Long Term Care Residents
  3. Incorrect Surgical Site
  4. Misreading Pathology Report Results in Omission of Treatment
  5. Wrong Site Surgery
  6. Fall Resulting in Fracture
  7. Failure to Change Treatment Plan Following Critical Test Result
  8. Fall with Hip Fracture
  9. Delay in Diagnosis/Treatment
  10. Pressure Injury
  11. Communication about Patient Goals of Care
  12. Medication Adverse Event
  13. Surgical Incision Awareness
  14. Gaps in Wound Care Services in Home Care Environment
  15. Unintended Dislodgement of Feeding Tube
  16. Delayed Diagnosis of Abdominal Pain
  17. Fall Resulting in Fracture
  18. Medication Error - Missed Dose of Neupogen
  19. Delay in Treatment Following Outpatient Surgical Procedure
  20. Unwitnessed Fall
  21. Improperly Charged Defibrillator During Cardiac Arrest
  22. Foreign Body Left in Client
  23. Fall from Mechanical Floor Lift
  24. Medication Administered to Incorrect Client
  25. Fall Resulting in Fracture
  26. Wrong Site Surgery
  27. Pressure Injury
  28. Medication Adverse Event in an Infant
  29. Myomectomy Complications
  30. Delay in Treatment
  31. Delay in Treatment
  32. Lack of Documentation
  33. Death by Suicide in Facility
  34. Aspiration Resulting in Death
  35. Delayed CT Scan
  36. Fall Resulting in Fracture
  37. Humeral Head Fracture
  38. Humeral Head Fracture
  39. Streptococcal A Sepsis Resulting in Death


  1. Incomplete Surgery
  2. Missed Amended Pathology Report
  3. Communication Between Departments
  4. All Results from Diagnostic Imaging Not Addressed
  5. Incorrect Surgical Procedure
  6. Lap Belt Strangulation
  7. Unwitnessed Fall Resulting in Fracture
  8. Methadone Dosing Error
  9. Fall From Bed With Fracture
  10. Sling Loop Migration Causing Fall From Ceiling Track Lift