The Montreal Health Department investigating after an operation was left “abandoned” on an empty infirmary
A series of mistakes resulted in a patient, still recovering from anesthesia and surgery, being left on an empty floor for hours without supervision or medical attention, Radio-Canada has learned.
The incident happened on the night of February 3 at Fleury Hospital in north Montreal, multiple sources have learned from Radio-Canada.
The patient, a firefighter by profession, was to be taken to the eighth floor for nighttime observation after an operation in the evening. However, the orderly mistakenly took him to the third floor, which was designated for daytime operations and is closed at night.
According to sources, the orderly saw someone in the hallway and assumed it was a nurse, when in fact it was a maintenance worker. The worker did not see the patient and then closed the door on the way out.
For hours, none of the medical staff noticed that the patient was missing. It wasn’t until his wife, who was waiting for him on the eighth floor, started asking questions around 1 a.m. that an employee went to investigate.
A coordinator went to the operating room but could not find the patient there. Despite this, nobody activated a yellow code to signal that the patient was missing.
The patient, who was recovering from anesthesia, woke up around 3 a.m. about two hours later with no one around. In his scrubs, with no cell phone, he found the strength to go to the nurses’ station, but there was no one there.
He then picked up the phone and called security, who reportedly hung up.
The man then called his wife to pick him up and the couple decided to leave the hospital. The patient’s vital signs and pain were assessed prior to discharge and he refused further treatment.
“He could have died 100 times”
Hospital and health officials say the case raises concerns about the quality of care being provided. (Radio-Canada has agreed not to name them as they are not authorized to speak to the media.)
“He could have died 100 times,” said a source not authorized to speak to the media.
“Everyone was shocked,” said another source. “It wasn’t supposed to happen.”
The state health department CIUSSS du Nord-de-l’Île-de-Montréalconfirmed a patient was taken to the wrong floor of Fleury Hospital on February 3. It said that after realizing the patient was missing, the medical team called the patient, who was able to speak to his surgeon.
“Our priority was to continue caring for the patient at home,” said CIUSSS spokeswoman Marie-Hélène Giguère.
What type of surgery the patient underwent is not yet known, but the CIUSSS said the surgery was on the upper body.
Paul Brunet, a patient advocate and President of the Council for the Protection of Maladessays patients are usually in much more vulnerable positions, which could have made this case “much more serious.”
“It’s hard to believe that once a patient is admitted, once registered, once operated, they leave as if they didn’t exist,” Brunet said. “He was literally written off. It sends chills down the spine.”
Ongoing investigation and reinforced measures
According to CIUSSS, the risk management team is currently investigating the incident in collaboration with the patient.
“Industrial relations are also involved in the investigation to understand the role and responsibilities of all employees and managers who intervened that evening,” the regional health agency said. “The teams have all been interviewed.”
“This type of incident is rare and we will do everything necessary to ensure that it does not happen again,” said Giguère.
She said that additional measures have already been taken to rectify the situation, e.g. B. Indicating where the patient is moving in their file and conveying this information orally to the staff responsible for the transfer. Day surgery is also receiving more inspection rounds, including outside of operating hours.
The CIUSSS confirms that this incident is considered a “sentinel event”, which the Ministry of Health defines as an event that requires in-depth analysis because it reveals errors in a process that have led or could have led to serious consequences. Such incidents are reported to the entire health network.
Health Minister Christian Dubé said in a statement the incident was “unacceptable and worrying”.
“It in no way represents the care that Quebecers deserve and need to have,” Dubé said. “A situation like this should never happen.”
