'Never events' lists hospital mistakes that should never happen in Canada

Surgery on the wrong body part or patient, leaving a sponge in a patient, and giving a patient the wrong tissue, egg, sperm or blood product are among a new Canadian list of 15 "never events" for hospitals.

Health Quality Ontario and the Canadian Patient Safety Institute released their report, "Never Events for Hospital Care in Canada," on Friday to highlight strategies to identify and reduce medical errors resulting in serious patient harm or death, and that are preventable.

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"Never events do not imply blame; 'never' is a call to action, not a demand or an attempt to shame mistakes," the report's authors said.

Many of the events occur only rarely, but can have a severe impact on patients.

The list includes:

• Surgery on the wrong body part or patient due to a mislabelled biopsy sample or because two patients have the same name.
• Wrong tissue, implant or blood product given to a patient, including blood or organs that are incompatible with a patient's blood type or the wrong donor egg or sperm.
• Unintended foreign object left in a patient, such as sponge or towel, after a procedure, regardless of whether harm occurred or if the object is discovered in hospital or after discharge.
• Patient death or serious harm arising from improperly sterilized instruments or equipment.
• Patient death or serious harm due to a failure to ask whether a patient has a known allergy to medication or giving such a medication even when the allergy had been identified.
• Patient death or serious harm as a result of one of five pharmaceutical events, such as giving chemotherapy the wrong way.
• Infant abducted or discharged to the wrong person.

While England and the U.S. have defined "never events," Canada has only now devised a universal list of them, said Chris Power, CEO of the Canadian Patient Safety Institute.

In Canada, Saskatchewan and Nova Scotia have already adopted similar lists.

The report was written by a team who researched, surveyed and consulted with health-system leaders, providers, patients and the public before recommending a list.

The authors plan to publicize and promote awareness of never events and to update the list based on new or improved data on occurrence and trends.