1. Safer patients, better care through
Never Events research and education
Canadian Patient Safety Institute
Virtual Forum on Patient Safety and Quality Improvement
October 2013
Outstanding care – every person, every day
Central CCAC

2. Groundbreaking research:
a Canadian first
• Central CCAC’s reality: 30,000+ patients a
day, 58% from hospital, 69% with high/very high
needs
• Central CCAC / University of Toronto study - incidents
that should never happen when delivering care in
the community
• Serious, preventable, reportable
• Generated recommendations for
clinical, administrative and policy strategies
• Strengthens accountability through performance measures
• Increases transparency through public reporting
• Supports Outstanding care – every person, every day
Central CCAC
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3. Key lessons learned
• Top four Never Events
Central CCAC’s
first focus
1. Adverse reaction requiring ED visit or
hospitalization due to med-related events
2. Serious injury related to inappropriate service plan
3. New peritoneal dialysis infection
4. Serious event related to care or services contrary to current
professional or other practice standards
• Complexities of care in community include patients
choosing to live at risk and informal caregiver involvement
• How to identify events, improve reporting systems
and support sustainable change – Everyone has a role!
Central CCAC
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4. Using the research to drive
safer patients, better care
• Building a shared community sector vision
where patients receiving home care never experience
a serious, preventable medication-related error
• Key steps
• Listening to patient and family feedback
• Process improvement sessions
• Never Events education:
 34+ workshops and webinars
 500+ frontline staff, service providers
 16 service provider organizations
• Measurement – Reporting of errors has increased
since education
Central CCAC
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