Image copyright Ontario Health Ministry Image caption A home of four children in Ontario was flooded twice in eight weeks.
The rapid response of Ontario authorities after an electrical surge at a children’s ICU has tested the system’s ability to respond to severe incidents.
A new report says the system failed in the emergency but says no one was injured.
It says authorities got on top of the problem in an hour, sending staff to home hospitals.
The report from Ontario Health Ministry officials and Royal University Hospital is addressing an incident involving four children in September.
In total, it took 24 hours to fix the electrical problem and 10 hours to fix it in the four-week period it happened, according to the report.
A surge from an electrical short in a handheld computer room forced a power cut, shutting down the four hospitals, according to the report.
While none of the children were injured, Staff at two private hospitals said they could not get information from the ambulance service because the hospital was fully functioning.
The power cut led to huge quantities of equipment being flooded with oxygen and cooled fluids.
People at two homes that housed the children said they had been warned by the providers that the families should do so but these warnings had not been acted upon, the report states.
“In short, the system that was created to meet the emergency did not have sufficient checks and balances in place,” the report states.
The system, the report adds, has few established processes, systems and procedures to deal with similar extreme incidents.
“When they do not have an adequate response mechanism, things like these events can occur,” it adds.
What the report recommends
The report calls for the system to be simplified and of good practice, and calls for training and supervision.
It also calls for a uniform response to ongoing incidents.
Despite the problems, no-one was injured during the incident in September, the report said.
The ministry’s acting chief medical officer of health, Prof Elizabeth Bennett, said: “As health care systems continue to respond to increasingly complex issues, it is clear that a uniform response to all adverse events is a significant benefit that must be examined and improved upon.”
The report notes there were several deaths involving ICU patients around the world in 2018.
In one case, in September 2018, a newborn baby boy from England died after a stroke in his hospital ICU.
A nurse used a generator without telling doctors or the mother about it.
Cases like this have prompted discussions in many countries, especially the UK.