New List of “Never Events” For Hospital Care in Canada

A group of Canadian health care organizations has created a list of patient safety incidents (known as never events) that should never happen in hospitals.

Background

Patient safety remains a priority for hospitals across the country. While patients expect safe health care and providers strive to continuously deliver excellent care, events that harm patients do occur. Although some level of risk is an inherent part of care, many events that cause harm can be prevented.

In January 2014, the Canadian Patient Safety Institute (CPSI) brought together health sector partners to form a National Patient Safety Consortium (NPSC). Working together, the consortium identified a list of 15 never events for hospital care in Canada. These events are outlined in a new report from Health Quality Ontario and the CPSI titled Never Events for Hospital Care in Canada (PDF), released in September 2015. The report also provides strategies to help identify and prevent these events from occurring.

What Are Never Events?

According to the report, never events are patient safety incidents that result in serious patient harm or death that are preventable using organizational checks and balances. Never events are not intended to reflect judgment, blame or provide a guarantee. Instead, never events represent a call to action for hospitals to prevent their occurrence.

List of 15 Pan-Canadian Never Events

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 hospital.
5. Patient death or serious harm due to a failure to inquire whether a patient has a known allergy to medication, or due to the 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 a pharmaceutical event including:
   • wrong-route administration of chemotherapy agents;
   • intravenous administration of a concentrated potassium solution;
   • inadvertent injection of epinephrine intended for topical use;
   • overdose of hydromorphone by administration of a higher-concentration solution than intended;
   • neuromuscular blockage without sedation, airway control and ventilation capability.
8. Patient death or serious harm as a result of failure to identify and treat metabolic disturbances (eg. hypoglycaemia in an admitted patient, hyperbilirubinemia in neonates).
9. Any stage III or stage IV pressure ulcer acquired after admission to hospital.[1]
10. Patient death or serious harm due to uncontrolled movement of a ferromagnetic object in an MRI area (eg. moving metal projectiles such as a pair of scissors).
11. Patient death or serious harm due to an accidental burn (eg. oxygen fires, heat or cold burns from assisted bathing, the use of hot or cold packs during wound care).
12. Patient under the highest level of observation leaves a secured facility or ward without the knowledge of staff (eg. patient with dementia, psychosis, or at risk of suicide).
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.

Strategies to Help Identify and Reduce Never Events

Recognizing and addressing never events is one aspect to providing and improving safe patient care. Strategies to help identify and reduce never events include:

• Building a hospital culture and environment where health care professionals, staff, patients and families feel safe to report and discuss adverse events or system failures.
• Instituting safety reporting and learning systems that track the incidence and frequency of never events, facilitate prompt management and analysis of the events, and report on improvements made over time. Publicly sharing what was learned from the review of events and any recommendations (where permitted by relevant legislation) is also recommended, as local efforts and initiatives to prevent never events will be of interest to other organizations across Canada and around the world.
• Identifying opportunities for improvement. Reporting mechanisms and open discussion of never events could further assist hospitals in identifying steps for improving patient safety. The sharing of best practices within and across organizations and geographies would also be complementary to this strategy.
• Continuous improvement supported by measurement and evaluation. Hospitals should consider the best way to measure and evaluate never events and other measures of process improvement.

Next Steps

The creation of the never events list is a call to action for hospital administrators and staff to improve patient safety by developing and adopting procedures to help ensure that never events do not occur in Canadian hospitals.

The NPSC will continue to promote the adoption of the never events list. The NPSC is also contemplating a companion to never events: always events. Always events would indicate best practices that should always occur during the care process.

We previously published related information on improving hospital patient care and transparency in Ontario through proposed amendments to the Public Hospitals Act, Regulation 965.

[1]       A Stage III pressure ulcer occurs when the sore becomes worse and creates a crater in the tissue. A Stage IV pressure ulcer occurs when the sore is very deep, causing extensive damage to muscle, bone and tendons. Stage III and IV ulcers can lead to serious complications including bone infections or sepsis.