Never Events Report Released for Canadian Hospitals and Health Care Facilities


Never Events are events that have been identified as events that could result in serious harm to a patient, and even result in their death, that should never happen to a patient in a Canadian hospital.  And significantly, these are safety incidents that are preventable.  Canada has released its first Never Event report, a joint effort between Health Quality Ontario and the Canadian Patient Safety Institute. 


According to the report, Never Events need to meet four criteria, namely

  1. They are serious and can result in serious harm or death to a patient;
  2. They can recur unless the issue(s) is dealt with;
  3. They are identifiable and specific;
  4. They are avoidable if the organization takes appropriate measures to prevent the event from happening again.


The following is excerpted from the “Never Events for Hospital Care in Canada, Safer Care for Patients,” released September 2015:


Foreword from the Canadian Patient Safety Institute


Patients rightfully expect safe care, and health care providers strive to deliver care that results in better health and safe outcomes for patients. Unfortunately, events that harm patients do occur while care is being provided, or as a result of that care. While risk is an inherent part of care, many of the events that cause harm can be prevented using current knowledge and practices.


There is tremendous activity to improve patient safety in Canada. There are quality and patient safety councils in most provinces, leaders from regional authorities and hospitals, as well as many national organizations who dedicate all or part of their mandate to patient safety.


In January 2014, the Canadian Patient Safety Institute (CPSI) brought together key health sector partners to form a National Patient Safety Consortium. The consortium strives to advance a national call to action for patient safety, and it is made up of more than 50 Canadian health care organizations that represent governments, health care professionals, patients and families, regulators, researchers, educators, enforcement agencies, and national and provincial agencies and associations. These partners share their expertise and work together to accelerate the pace, spread and scale of patient safety improvement.


Last year, the consortium identified a number of priority actions, one of which was to bring together a group of volunteer partners to research and recommend a list of never events in Canadian health care; this group became the Never Events Action Team. Health Quality Ontario provided leadership in collaborating with the organizations that volunteered to join this team.


One such Never Event is


“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

When frail patients or those with dementia are transported home or to another facility or ward, they must be left with appropriate support. It is crucial that those providing transport ensure the patient is left in a safe environment and with proper notification given to caregivers.”


This is an example where care givers can help prevent a serious incident, by ensuring that the hospital or health care facility has full and correct contact information, and by asking specifically to be informed of any transport arrangements that could be made.


The National Patient Safety Consortium is now looking at producing a companion report to Never Events, which is Always Events.   These are best practices for caring for patients in hospitals and other health facilities.  These Always Events will help to strengthen patient safety in Canada. 


For the full report, go to


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