"We call them critical incident learning summaries," said Dr. Rob Robson, the WRHA director of patient safety.

He said not taking responsibility for a mistake adds insult to injury. The reports will tell a patient and family, "We just want you to know we're trying to learn so it doesn't happen to someone else. We're sorry about this happening.... It may provide some level of comfort to the family." The WRHA may also discuss compensation -- a tact that may actually save the health system money, he said.

The WRHA has a team of 10 investigators -- all nurses -- which looks into the critical incidents. When the team's reports are released to the Manitoba hospitals, medical schools and care homes, the patient is "de-identified" to protect the privacy of their personal health information, Robson said.