--0000000000001beda8063c6a288e Content-Type: multipart/alternative; boundary="0000000000001beda7063c6a288c" --0000000000001beda7063c6a288c Content-Type: text/plain; charset="UTF-8" Content-Transfer-Encoding: quoted-printable I have attached the incident reports. *Carolyn Daoust* Gestionnaire des Ressources Humaines/Employee Care Manager Ressources Humaines/Human Resources 514-907-5065 TheKey.ca [image: TheKey] On Fri, Aug 15, 2025 at 12:37=E2=80=AFPM Carolyn Daoust wrote: > Would the information below be sufficient, Timothy? > _________________________________________I&A Report: 2025 > > Detailed Incident Summary > > In 2025, three separate incidents were documented, involving two client > falls and one medication error. > > - > > *Dr. Khoday (February 12, 2025): *The client was in the kitchen when > she suddenly got dizzy and fell forward onto her knees. The caregiver > heard the fall from another room and came to assist. The client > experienced pain in her knees and had difficulty walking afterward. > > - > > *Mme Paulette Marcotte Lafleur (July 19, 2025):* After returning from > dinner, the client was settled in a chair. When the caregiver briefly > went to the washroom, the client attempted to get up with her walker; = the > walker pushed forward, and she fell onto her buttocks. No immediate > injuries were reported, but she was later taken to the hospital as a > precaution. > - > > *Mrs. **Carolyn Wilkinson Kott (August 2, 2025):* A medication error > occurred when the evening caregiver administered an old medication. Th= e > daytime caregiver had sent a text with instructions from the pharmacis= t not > to take the old medication, but the evening caregiver did not see the > message in time. The client did not suffer any injury from the error. > > > ------------------------------ > > Root Cause Analysis > > The underlying causes of the 2025 incidents were varied, pointing to > client health, equipment use, and internal communication processes. > > - > > *Acute Client Health Event*: Dr. Khoday's fall was directly caused by > a sudden bout of dizziness, a physiological event that could not have = been > anticipated by the caregiver at that moment. > > - > > *Unsupervised Client Action & Equipment Misuse*: Mme Lafleur's fall > was a result of her attempting to get up on her own combined with the > walker moving forward. This indicates a risk associated with clients > who have a known history of falls attempting to ambulate without direc= t > supervision, even for a moment. > > - > > *Communication Process Failure*: The medication error for Mrs. Kott > was caused by a reliance on a non-secure, passive communication method > (text message) for a critical, time-sensitive instruction. The failure > was not in the sending of the information but in the lack of a system = to > confirm it was received and understood before the medication was due. > > > ------------------------------ > > Corrective Actions and Follow-up > > Immediate and subsequent act