‘By reporting these incidents, Horizon staff assists in driving quality improvement, improving safe patient care’ – Horizon Health
The Upper River Valley Hospital (URVH) in Waterville recorded a total of 444 harmful incidents at the healthcare facility in the past four years, and three involved the death of a patient in 2022 and 2023.
Under a Right to Information Request (RTI) filed by the River Valley Sun, Horizon Health Network released its records of URVH incidents where patients were harmed between 2020 and 2024. The documents were requested from the Horizon Health Risk Management Department.
A harmful incident at a hospital is defined as an event or circumstance that results in unnecessary harm to a patient or group of patients. These incidents can stem from various sources, including medication errors, infections, falls, bruising requiring a dressing or ice, unsafe procedures, and mistakes made by healthcare professionals.
According to the Canadian Institute for Health Information, one in 17 hospital stays in Canada involves a harmful incident.
In 2023, one patient at the Waterville hospital died from a fall on Floor 2 East in the medical/surgical/palliative care unit. Another death occurred that same year on Floor 2 West in Labour and Delivery. In 2022, a patient died during a harmful incident in the operating room.
Between 2020 and 2022, there were 170 harmful incidents at the hospital, with 94 occurring in 2020 and 75 in 2021. There was only one reported incident of harm in 2022.
Within those two years, 101 incidents involved a patient falling; four falls were recorded as serious. Most falls occurred on Floor 2 North (44 falls) in the alternative care unit for seniors and on Floor 2 East (33 falls) in the medical, surgical, and palliative care areas.
There were 36 incidents related to medication dispensing, 18 of which were classified as serious. Between 2020 and 2022, eight harmful incidents occurred in the operating room, with five classified as serious. Another 26 incidents involved treating a patient in various hospital areas; four were serious. One serious incident in 2020 involved a patient being treated in the obstetrics department.
Between 2022 and 2024, a total of 274 harmful incidents were recorded at the Waterville hospital, with 115 occurring in 2022, 72 in 2023, and 87 in 2024.
Within that time, 170 incidents involved a patient falling, and five falls were severe. Of those, 69 falls occurred on Floor 2 North in the alternative care unit for seniors, and 67 falls happened on Floor 2 East in the medical, surgical, and palliative care unit.
Between 2022 and 2024, 25 medication variances were listed as harmful, with four of these occurring in the oncology clinic for cancer patients. Another 60 incidents at the hospital were linked to patient treatment, with three described as severe.
In the emergency department, 18 incidents occurred, including four falls and five incidents involving patient treatment. Five security issues were also reported in emergencies between 2022 and 2024.
Greg Doiron is the Vice-President of Clinical Operations for Horizon Health. In a statement to the River Valley Sun, he noted that 41,000 harmful incidents were reported and reviewed across Horizon Health between January 2022 and December 2024.
Of these, 79.5 per cent were near misses or no patient harm. Less than one per cent of reported incidents were identified as severe or causing greater harm.
“Incident reporting is embedded in Horizon’s culture of patient safety,” Doiron said. “All incidents, including near misses and all degrees of harm – from no harm and mild to severe – are reported and reviewed, and action is taken to reduce and mitigate the risk of the incident reoccurring.
“By reporting these incidents, Horizon staff assists in driving quality improvement and improving safe patient care. It’s important to learn from these incidents in order to prevent future occurrences and mitigate the risks to patient safety.
“To achieve this, Horizon’s patient safety culture creates a blame-free environment where incidents are looked at through a ‘systems perspective lens’ focusing on system and process failures. Horizon commits to continuously improve quality, safe care and services to all patients.”
Horizon Health operates 12 hospitals, over 100 medical facilities, and clinics across New Brunswick.
In an earlier Right to Information request, the River Valley Sun received additional data on healthcare delivery at Waterville. Between 2020 and 2024, 157 public complaints were filed about the hospital. These complaints focused on the quality of care, wait time, and behaviour and attitude of staff, including medical and nursing staff.
Horizon Health records indicated that all complaints were handled internally by the head of the emergency department, an attending physician, a nurse manager, an executive and administrative director, or a facility manager.
Laura Russell of Canterbury has been waiting almost a year for her concerns about URVH to be resolved and is now taking her concerns to the Ombud NB in Fredericton. She hopes to have a meeting with that office soon.
“I’m still making waves,” said Russell. “I’m going to continue trying to get answers. There is certainly something wrong with the health care system.”
Russell said she is determined to discover why important information is being withheld.
After the death of her loved one at URVH in April of 2024, she confronted hospital staff, wrote letters, and contacted the provincial Department of Health to request a review of medical care being delivered in Waterville. She disagreed with the drugs her senior was given, even though it is considered a regular practice for many elderly in care.
In August 2024, Russell met with a patient advocate from Horizon Health in Fredericton to discuss her concerns, but received no reply despite follow-up calls and emails.
In October 2024, Russell wrote again to Margaret Melanson, the president and chief executive officer for Horizon Health, with no reply. She noted Melanson was the patient advocate she met with in August.
Russell wants to see the results of a CAT scan given to her loved one, whom she was told had terminal cancer. She recently discovered that she was named as the next of kin on his medical file. She wants evidence of his cause of death and answers about why her concerns about his care were not respected.
Within the first RTI package from Horizon Health, information was provided about various hospital policies, including the management of patient and family feedback and concerns.
This policy outlines an “escalation process” for patients and families who are not satisfied with the investigation of their complaint, noting that they can seek further assistance with their case from the Ombud NB or the NB Seniors Advocate.
Horizon Health also shared policies on patient safety and “harmful incidents,” which outline definitions for an apology from a hospital and the disclosure of information by healthcare providers.
The policy on patient safety states: “employees, medical staff, students and volunteers are accountable to ensure patients and families as partners in care leading to improved health, quality of life and well-being.”
