Never Events

Since 2024, hospitals have voluntarily reported never events to Ontario Health to foster learning and drive quality improvement. This initiative builds on the foundational 2015 report Never Events for Hospital Care in Canada.

Prevention and Implementation Planning Resources

To strengthen our collective efforts, Ontario Health is overseeing a prevention and implementation plan. The plan includes a series of prevention placemats: concise, evidence-informed tools that offer practical clinical guidance and curated resources. These placemats support each of the 15 events currently being voluntarily reported in hospitals across Ontario, across five categories: prevention of pressure injuries and surgical-, medication-, procedural-, and discharge-related events.

Each placemat is designed to help health care teams implement safer care practices and reduce the occurrence of preventable harm. 

For additional resources, visit Quality and Patient Safety Program.

Prevention Placemats Series

• Pressure Injuries
• Surgery-Related Events:
  • Overview
  • Wrong Body Part, Wrong Patient, or Wrong Procedure
  • Wrong Tissue, Biological Implant, or Blood Product
  • Unintended Foreign Object Left in a Patient
  • Use of Improperly Sterilized Instruments or Equipment

Learn More

For more information or any questions, please contact: QualityandPatientSafety@ontariohealth.ca.