It’s Time to Tackle Never Events

According to a recently published analysis, approximately 25% of hospitals fall short of the Leapfrog Group’s standards when it comes to addressing and responding to patient harm events, often referred to as never events. The report revealed that 74.5% of 2,000+ hospitals that provided feedback on the 2018 Hospital Survey issued by Leapfrog adhered to all 9 items of its never event policy.

Who is Leapfrog?

The Leapfrog Group is a nonprofit, national, independent organization founded over a decade ago by top employers and private health care experts in the U.S. The organization’s goals include supporting and fostering the quality, safety, and affordability of health care in the U.S. through the collection of data and public reporting.

The organization endeavors to save lives by reducing medical errors, infections, accidents, and injuries. It publishes the annual Leapfrog Hospital Survey, enabling you to focus on evaluating and publicly reporting hospital performance. The survey promotes transparency and is a trusted evidence-based tool in which some 2,000 hospitals participate at no cost.

The Leapfrog Group solicits quality and safety data from hospitals across the nation.

Never events policy

The National Quality Forum has defined 29 events as serious patient safety errors that should be reported when they occur. These events are frequently referred to as never events and include deaths due to medication errors, wrong site surgery, and leaving medical tools inside a patient after surgery. These events are rare, but when they do occur they are often extremely detrimental to the patient’s health or even result in death.

The never event policy issued by The Leapfrog Group has been included in its survey to hospitals since 2008. The policy was updated in 2017, with the addition of 4 actions which brought the total number of actions to 9.

The Leapfrog policy specifies the 9 actions referred to above that a hospital should take if even one of the 29 never events happens. A sampling of these 9 actions include: canceling all costs related to the event, apologizing to patients, reporting the medical error to an outside agency, interviewing the patient and his or her family to compile evidence for determining the root cause, and supplying patients and payers with the hospital’s adverse event policy upon request.

The Leapfrog Group developed the never event policy from feedback obtained from reviews of medical literature in addition to patient safety experts. The policy was updated a couple of years after the Agency for Healthcare Research and Quality produced a toolkit for healthcare providers to deal with patient harm events. A portion of that toolkit is now included in the Leapfrog policy, such as a protocol to support medical caregivers who are involved in never events.

The Never Event Policy promoted by Leapfrog is part of a nationwide effort to achieve the same level of dependability in health care that other high-risk industries such as aviation have obtained. Patients place their lives in the hands of health care practitioners on a daily basis. As Binder states, “our lives are worth the same when we walk into the hospital as when we board a plane.”

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