Canadian health organizations in a new report are raising awareness about preventable safety incidents in hospitals that lead to patient harm or death, otherwise known as “never events.”
The report, “Never Events for Hospital Care in Canada,”was written by a consortium of Canadian health quality organizations and identifies 15 avoidable never events that take place in hospitals.
“We created this report with the Canadian Patient Safety Institute to help increase awareness for incidents that can be prevented," said Joshua Tepper, MD, president and CEO of Health Quality Ontario, in a statement. “We hope that by calling attention to these 15 never events, Canadian hospitals will rally around them and harness their collective knowledge, expertise and experiences to prevent them from happening.”
The Health Quality Ontario with support by the Canadian Patient Safety Institute spearheaded the report, which was written by a group of organizations known as the Never Events Action Team.
Some of the listed never events include: wrong tissue, biological implant, or blood product given to a patient; patient death or serious harm as a result of one of five pharmaceutical events; failure to identify and treat metabolic disturbances; and instances where patients die or suffer serious harm because the hospital failed to ask whether a patient had a known allergy to medication, or where an allergy was identified but medication was still administered to the patient.
Accidental death or injury may also occur in cases where patients are administered the wrong gas, suffer burns during the care process, or if metabolic disturbances aren’t identified and treated.
A list of never events isn’t adequate to resolve errors in hospitals, the report’s authors emphasize. “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 report highlights a number of strategies to help identify and reduce these events. It recommends that organizations foster a culture that encourages reporting of system failures and other adverse events. “Organizations should embrace these opportunities to learn and improve. Strong leadership within teams and organizations and the involvement of patients and families can and should propel this culture,” according to the report.
To more efficiently manage these types of events and determine when they’re most likely to occur, organizations should take steps to track and report these incidents, and openly share and discuss what they find, while identifying strategies to avoid such events in the future, the report’s authors suggested.