Auditor’s report focuses on critical health incidents, cannabis regulation

Saskatchewan’s auditor is being critical of the health-care system’s handling of critical incidents.

In her 2021 report released Tuesday, Judy Ferguson says the Saskatchewan Health Authority and the Ministry of Health have missed opportunities to make patients safer by under-reporting critical incidents or by not implementing changes quickly enough after receiving those reports.

The report says a critical incident “is a serious adverse health event that did or could have resulted in serious harm or death of a patient.”

Since 2004, health-care organizations have had to report those incidents to the ministry and make changes to address the causes of the incidents. The ministry then monitors the progress of those changes.

“On an overall basis, we found the ministry is missing opportunities to use critical incident reporting to improve patient safety,” Ferguson said Tuesday. “For example, we found the type of incidents requiring reporting is narrower than good practice. For example, they do not include reporting of serious infections as Ontario does.

“The ministry last updated the types (of incidents) requiring reporting in 2004. 2004 was the year that the reporting requirement first came into effect. We think it’s time for an update.”

Ferguson’s report said there were 290 critical incidents reported in 2019-20. In 91 of those, a patient died.

However, the auditor said there is significant under-reporting of incidents to the ministry.

She noted between December of 2019 and September of 2020, the SHA reported 17 critical incidents involving medical devices to the ministry, but the authority reported 24 such incidents to Health Canada.

“Under-reporting may reflect staff not having sufficient awareness of the requirement, being reluctant to report or not having sufficient or clear understanding of types of incidents to report,” Ferguson said.

She also noted the ministry receives one-third of critical incident reports later than is required by law, including some that arrive more than 200 days after the incident occurred.

Delays like that, Ferguson said, create delays in making plans to deal with the cause of the incident.

As well, the report said the ministry doesn’t always check to see if the SHA made the suggested changes to address the cause of the critical incident. The report said 68 per cent of the changes recommended in critical incident reports examined by the auditor weren’t implemented.

The four most recognized critical incidents were pressure ulcers, falls that cause death, suicides while in care and medication errors. Ferguson’s report suggested the ministry should do a better job of issuing patient alerts in those areas to raise their profile for health-care workers.

“Effective use of critical incident reporting should reduce, over time, the degree of injury and the types of critical incidents that occur in Saskatchewan health-care facilities,” Ferguson said.

Health Minister Paul Merriman said the ministry has accepted all of Ferguson’s recommendations and is in the process of examining what has to be done to implement them.

SHA CEO Scott Livingstone said the reporting of critical incidents is done manually in the province, so the authority is examining an electronic system to speed up that process and to track near-misses.

The goal, he said, is “getting to improved processes and improved quality of care before there is an adverse event.”

“The critical incident process is done so that the system is a learning system and we learn from those mistakes or near-misses so that we can improve the quality and the safety of care moving forward …,” Livingstone said.

“We are working both with the ministry and other health system partners to expedite some of the recommendations.”

Cannabis regulations

Ferguson also said it was time for tighter regulation of recreational cannabis businesses in the province.

The Saskatchewan Liquor and Gaming Authority is educating businesses that get permits to sell marijuana, but the authority has yet to start punishing companies that don’t follow the rules.

“You need to move to that enforcement action to make sure that you are properly regulating this area,” Ferguson said.

The auditor said inspectors have found some businesses that aren’t asking buyers for ID to make sure they’re allowed to buy cannabis, some that are selling or advertising products they’re not allowed to sell, and others that aren’t doing the required video logging.

Ferguson said the SLGA should start fining companies that aren’t following the rules instead of just trying to educate them.

She said at the time of the audits, three warning letters had been sent out, but no fines had been issued. But she added the SLGA sent out a notification April 30 that it was planning to move to enforcement.

“You set up a regime that lets people know that they will be inspected (and) that the logs will be looked at and that operates really as a deterrent factor in terms of making sure that the guys who are running the stores and the permittees know that this is a regulated industry,” Ferguson said.