Never Events for Hospital Care in Canada

Providing safe healthcare is a continual and evolving process that requires input and collaboration by everyone in the system. As a country, we have not pursued agreement on a list of “never events” – until now.

Never events are patient safety incidents that result in serious patient harm or death, and that can be prevented by using organizational checks and balances.

Never Events for Hospital Care in Canada is the first Pan-Canadian report of its kind and an important step towards the prevention of never events in Canadian healthcare settings.

The team researched, surveyed and consulted with health and safety leaders from across the country, and patients and the public, to reach consensus on a list of 15 never events for Canada’s healthcare system:

1. Surgery on the wrong body part or the wrong patient, or conducting the wrong procedure
2. Wrong tissue, biological implant or blood product given to a patient
3. Unintended foreign object left in a patient following a procedure
4. Patient death or serious harm arising from the use of improperly sterilized instruments or equipment provided by the health care facility
5. Patient death or serious harm due to a failure to inquire whether a patient has a known allergy to medication, or due to administration of a medication where a patient’s allergy had been identified
6. Patient death or serious harm due to the administration of the wrong inhalation or insufflation gas
7. Patient death or serious harm as a result of one of five pharmaceutical events:
   1. Wrong-route administration of chemotheraphy agents, such as vincristine administered intrathecally (injected into the spinal canal)
   2. Intravenous administration of a concentrated potassium solution
   3. Inadvertent injection of epinephrine intended for topical use
   4. Overdose of hydromorphone by administration of a higher-concentration solution than intended
   5. Neuromuscular blockade without sedation, airway control and ventilation capability
8. Patient death or serious harm as a result of failure to identify and treat metabolic disturbances
9. Any stage III or IV pressure ulcer acquired after admission to hospital
10. Patient death or serious harm due to uncontrolled movement of a ferromagnetic object in an MRI area
11. Patient death or serious harm due to an accidental burn
12. Patient under the highest level of observation leaves a secured facility or ward without the knowledge of staff
13. Patient suicide, or attempted suicide that resulted in serious harm, in instances where suicide-prevention protocols were to be applied to patients under the highest level of observation
14. Infant abducted, or discharged to the wrong person
15. Patient death or serious harm as a result of transport of a frail patient, or patient with dementia, where protocols were not followed to ensure the patient was left in a safe environment

Sources: 

• For a full description of never events for Canadian healthcare settings, refer to the report: Never Events for Hospital Care in Canada
• To learn more about this important step for Canada’s healthcare system, visit the Canadian Patient Safety Institute (CPSI)