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Leapfrog Group Position Statement on Never Events

On November 15, 2006, the National Quality Forum released a newly revised list of 28 events that they termed “serious reportable events”, extremely rare medical errors that should never happen to a patient. Often termed “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. This is an update of NQF’s original 2002 report. Click here to see NQF’s “Never Events” list.

Never events are indeed quite rare and Leapfrog recognizes that processes sometimes fail and humans do make mistakes. However, The Leapfrog Group wants to give public recognition to hospitals that are willing to take all the right steps in the rare event that a serious reportable adverse event occurs in their facility. Leapfrog’s attention to the issue of never events is not intended to be punitive; rather, Leapfrog applauds hospitals that make aggressive attempts to learn from their mistakes, publicly disclose them, and make every effort to prevent the mistakes from ever happening again.

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, health plans, consumer advocacy groups and its own members in the manner outlined below.

In 2007, The Leapfrog Hospital Survey began asking hospitals about their process for handling serious reportable events. The Leapfrog Group gives public recognition to hospitals if they agree to the following if a never event occurs within their facility:

  • We will apologize to the patient and/or family affected by the never event
  • We will report the event to at least one of the following agencies: The Joint Commission, as part of its Sentinel Events policy*; state reporting program for medical errors; or a Patient Safety Organization
  • We agree to perform a root cause analysis, consistent with instructions from the chosen reporting agency
  • We will waive all costs directly related to a serious reportable adverse event
  • We will make a copy of our policy available to patients and payers upon request

The Leapfrog Group and its members have partnered with health plans through the Leapfrog Health Plan User Groups and Health Plan Lily Pad to encourage contracted hospitals to agree to the five steps outlined above for receiving public recognition. To date, the following health plans have issued a non-payment policy that mirrors Leapfrog's policy: Aetna, Cigna, Humana, MVP Healthcare, Partners Healthcare, Wellpoint/Anthem, and many of the local Blue Cross Blue Sheild Association chapters. In addition, states such as NY Medicaid, Pennsylvania, Massachussets, and Washington have also issued similar policies.

Leapfrog guides its members to state their public support for hospitals who take this stance by signing on in support of this Leapfrog Group statement.  The following have already done so:

  • Aetna
  • Caterpillar Inc.
  • Colorado Business Group on Health
  • GM
  • Hannaford Brothers
  • Health Net, Inc.
  • Health Policy Corporation of Iowa
  • HealthCare 21 Business Coalition
  • IBM
  • Indiana Employers Quality Health Alliance
  • Iowa Health Buyers Alliance
  • Memphis Business Group on Health
  • Midwest Business Group on Health
  • National Business Coalition on Health
  • Nevada Health Care Coalition
  • New Jersey Healthcare Quality Institute
  • New York Business Group on Health
  • Pacific Business Group on Health
  • Savannah Business Group on Health
  • St. Louis Area Business Health Coalition
  • The Dow Chemical Company
  • UPS

Other related documents:

 

*Reporting of Sentinel Events to the Joint Commission is voluntary for its accredited hospitals.