CPSI: Never events for hospital care in Canada (September 2015)

Summary

This report represents the collective work of the National Patient Safety Consortium to identify, for the first time, a list of 15 never events for hospital care in Canada. Never events are patient safety incidents that result in serious patient harm or death and that are preventable using organisational checks and balances. Never events are not intended to reflect judgment, blame or provide a guarantee; rather, they represent a call-to-action to prevent their occurrence.

But a list of never events won’t solve anything on its own. For it to have meaning, we need to take deliberate steps to identify when they occur, and harness the knowledge in hospitals across the country to prevent never events from happening. The Canadian Patient Safety Institute (CPSI) encourages a culture of continuous quality improvement — where mistakes are openly reported, disclosure occurs routinely and open discussion and problem solving are encouraged — with patients and families as full and active participants.