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Never Events – a Board Team Responsibility

Never Events

What are Your Agency's Never Events, and what is your Role?

Boards are required to monitor risk, and this responsibility is a key oversight function for governance teams. Front line staff as well as leaders work together to ensure client safety. The top of your Board Team’s list of risks should be populated by what your agency considers Never Events. (1)  These are the risks which present the greatest potential harm for your clients.

The publication of Never Events for Hospital Care in Canada, by the Canadian Patient Safety Institute  (CPSI) in 2015 is a key trigger for positive change in the sector. (2)  However, Client Centered Governance ® Board Teams use a "never events"  approach, regardless of whether or not they are in the health care sector. Risk management in the absence of knowing what the most serious potential occurrences may be for your agency is the opposite of good governance. CPSI defines Never Events as:

Never events are patient safety incidents that result in serious patient harm or death and that are preventable using organizational 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.

Beyond an understanding of what the Never Events for your agency are, CPSI also advises:

Boards should be monitoring other events that can and should be improved and might indeed be included in the never event category in the future.

No Agency is Immune to Error - For smaller organizations in the Community and Home Support Sector, it may be challenging to stay on top of risk management requirements, as staff resources to manage the measurement, monitoring and data collection may be limited. And so, it is key for the Board to have a strong governance – operations relationship in place to help ensure open discussion and decision making in this area. Questions which need to be discussed include:

  • What are the issues your CEO and staff may have in managing risk?
  • Is the list of Never Events available for your agency or sector?
  • If not, how can this be developed and used both for effective governance and in operations.
  • What is the Risk Management system in place and is the Measurement and Monitoring data available to the Board effective as decision support?

Quality results and client safety depend on it.

What are Examples of Never Events? There are 15 occurrences on the 2015 CPSI Never Events list. Here are some examples:

  • Surgery on the wrong body part or the wrong patient, or conducting the wrong procedure
  • Wrong tissue, biological implant or blood product given to a patient
  • Unintended foreign object left in a patient following a procedure
  • Patient death or serious harm arising from the use of improperly sterilized instruments or equipment provided by the health care facility
  • Patient death or serious harm due to a failure to inquire whether a patient has a known allergy to medication, or due to administration of a medication where a patient’s allergy had been identified
  • Infant abducted, or discharged to the wrong person

A list of “Other Events Considered But Not Deemed To Be Never Events” is included in the document. These events include serious occurrences such as

  • Any instance of care ordered by or provided by someone impersonating a physician, nurse,pharmacist or other licensed health care provider  and
  • Patient death or serious harm due to spinal manipulation while the patient is being cared for in a health care facility

A Positive Approach - The report provides important areas for Board and Leadership Team discussion. We suggest a discussion in the “Quality & Safety” section of your board meeting agenda based on the following statement from the CPSI report, as a starting point:

  1. Culture - Our system must nurture just and trusting cultures that recognize that never events can occur but can also be prevented.  

  1. Board Team is the Client Centered Governance ® term for the Board + the Leadership Team and the Executive Assistant.
  2. We highly recommend the CPSI’s Effective Governance for Quality and Patient Safety program for Board Teams in the health and community support sector. Other resources and tools are also available on the CPSI website.

Have a great week!

Gisele Guenard, Principal – VisionarEase & associates

We are positive Change Leaders / Leadership  l  Governance  l  Coaching

VisionarEase is Celebrating 10 Years serving Great Clients Across Canada!


(1)    Governance information provided by VisionarEase Inc. & associates is of a general nature and intended to encourage discussion and board development.  Governance and the legislation which directs it is in constant transformation. VisionarEase Inc. is in no manner liable for any decision or action taken by any individual or entity based on information shared by VisionarEase or its agents in any way including by electronic, written or verbal means. The information shared is not in any manner advice from the legal, finance, human resource or other professional field.  You are advised to consult pertinent professional counsel for up to date information, and we would be pleased to refer you to such counsel.


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