Processes fail. Humans make mistakes. But there are some errors so egregious that they should never happen to a patient under any circumstance.

Never Events

There are some errors so egregious that they should never happen to a patient under any circumstance.

In 2006, the National Quality Forum released a list of 29 events that they termed “serious reportable events,” extremely rare medical errors that should never happen to a patient. Often called Never Events, these include errors such as surgery performed on the wrong body part or on the wrong patient, leaving a foreign object inside a patient after surgery, or discharging an infant to the wrong person. 

That same year, the Centers for Medicare & Medicaid Services came out with a public statement on Never Events, in which it announced its intention to work with Congress, hospitals, and other health care organizations to reduce payments for Never Events and to provide more information to the public about when they occur.

 

Leapfrog Takes Action

In 2007, The Leapfrog Hospital Survey began asking hospitals about their process for handling serious reportable events. Since Leapfrog declared these principles as our standard, new research and experience have further informed evidence on best practices for addressing never events. In particular, AHRQ developed, tested, and launched the CANDOR Toolkit, and the National Patient Safety Foundation gathered stakeholders to propose new approaches to performing root cause analysis. As a result, Leapfrog has added four additional principles to its policy statement beginning in 2017, to further ensure that patients and families, as well as caregivers, receive appropriate follow-up if a never event occurs. A hospital "fully meets standards" if they agree to all of the following if a Never Event occurs within their facility:

1. Apologize to the patient and family
2. Waive all costs directly related to the event
3. Report the event to an external agency
4. Conduct a root-cause analysis of how and why the event occurred
5. Interview patients and families, who are willing and able, to gather evidence for the root cause analysis
6. Inform the patient and family of the action(s) that the hospital will take to prevent future recurrences of similar events based on the findings from the root cause analysis
7. Have a protocol in place to provide support for caregivers involved in Never Events, and make that protocol known to all caregivers and affiliated clinicians
8. Perform an annual review to ensure compliance with each element of Leapfrog’s Never Events Policy for each never event that occurred
9. Make a copy of this policy available to patients upon request

Read the original press release here.

Are Hospitals Making Progress?

Recognizing that these kind of errors can happen, Leapfrog applauds hospitals that make aggressive attempts to learn from their mistakes, publicly disclose them, and make every effort to prevent the mistake from ever happening again. Many hospitals already have a suitable policy in place.

But by the latest estimates, nearly one in five hospitals does not. 

"Never Events are a symptom of a health care system that is broken and unresponsive." - National Partnership for Women & Families President Debra L. Ness

 

Hospitals often fear that issuing a formal apology opens up a door for malpractice suits. Ironically, research indicates that malpractice suits are often the result of a failure on the hospital’s part to communicate openly with the patient and apologize for its error.

Patients feel the most anger when they perceive that no one is willing to take responsibility for the adverse event that has occurred. But a sincere apology from the responsible hospital staff can help to heal the breach of trust between doctor/hospital and patient.

Adding Surgery Centers to Public Reporting 

In 2020, Leapfrog started publicly reporting on surgery centers as well including asking if they have a Never Events Policy in place. 

Commitment to Patients and Purchasers

To create an environment that supports making serious reportable adverse events even more rare than they are today, The Leapfrog Group is committed to cooperate with hospitals, surgery centers, health plans, consumer advocacy groups to ensure that patients receive the treatment they deserve when a Never Event occurs.