Health Quality Ontario, in conjunction with the Canadian Patient Safety Institute, has come up with a list of 15 “never events” for hospital care in Canada. These events are incidents that can–although rarely do–occur during hospital care and result in serious risks and even death for patients.
A number of representatives from organizations such as Patients for Patient Safety Canada and the College of Family Physicians conglomerated to form the Never Events Action Team. Together, the team collectively released a report that highlights risks and aims to mitigate them by raising awareness and outlining how to best prevent the specific events. The report focuses on events than can be reliably prevented as opposed to only sometimes prevented.
These events only account for a small portion of patient care; however, the outcomes are severe if not prevented. There are drastic instances in hospital care that can be reduced, however this report focuses on events that can be eliminated if proper precautions are taken.
Some examples of never events include surgery done on the wrong body part or patient due to patients having the same names, or a mislabelled biopsy and unintentionally leaving foreign objects such as sponges or towels in patients. Leaving objects during surgery is a mistake that can be discovered post-operation through imaging and can have drastic outcomes if not handled. The report also includes specific events such as pressure ulcers formed after a patient is admitted into the hospital. Patient death due to unknown allergies is another example of a never event. A simple question and careful monitoring can prevent this event from occurring. Each of these events can be easily avoided if the appropriate steps are taken.
Infant abduction and patient suicide is also highlighted in the report.
The report also makes note of pharmaceutical events that can lead to the death of a patient. It highlights five specific events, such as an epinephrine injection that was intended for topical use, or administering a higher concentration of solution than needed. The report also includes a list of instances that were considered but not deemed never events, and reasoning for it.
Countries such as England and the United States already have a similar list of never events in place. Provinces such as Nova Scotia and Saskatchewan have a report of never events, but this is the first time a report like this has been made for Ontario. In the instance that any of these events were to occur, it could mean fatal outcomes for patients; not to mention legal liability for the hospital in question. The never events report stresses instances that are preventable through strong clinical and organizational systems, and careful observation of patients.