Never Events in Acute Care: Policy Lessons from International Comparisons

Rapid Review 29

Bhatia D., Lynch M., Murmann M., Roerig M., Allin S., & Marchildon G.

Report – EN [PDF]

Patient safety incidents are estimated to be the third-leading cause of death in Canada among the highest in the OECD. To tackle this problem, six indicators of never events—serious patient safety incidents that “should never occur”—were developed to standardize measurement and enable international comparisons. This report scrutinizes the one such indicator, Retained foreign object (RFO), defined as a “failure to remove surgical instruments at the end of a procedure.” We describe and assess the policy interventions aimed at reducing RFO incidents and other never events in England, Ireland, and New Zealand to identify policy lessons of interest to Canadian decision makers. No single intervention is sufficient, suggesting that multiple layers of protection are required to reduce the possibility of patient harm. We conclude that improvements in the Canadian context may require establishing an independent patient safety authority, external regulators, transparent and independent investigation processes, mandatory reporting, and clear and enforceable reporting policies.