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 its 2007 Quality and Safety Survey, The Leapfrog Group will give hospitals the opportunity to receive public recognition for agreeing 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: Joint Commission on Accreditation of Healthcare Organizations (JCAHO), as part of its Sentinel Events policy*; state reporting program for medical errors; or a Patient Safety Organization (e.g. Maryland Patient Safety Center)
• 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

The Leapfrog Group and its members will partner with health plans through the Leapfrog Health Plan User Groups and Health Plan Lily Pad to encourage contracted hospitals to agree to the four steps outlined above for receiving public recognition.

The Leapfrog Group and its members will work with national and local consumer advocacy groups to encourage hospitals to agree to the four steps outlined above for receiving public recognition.

Leapfrog will guide 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
• Community Health Foundation of Western and Central New York
• GM
• Hannaford Brothers
• Health Policy Corporation of Iowa
• HealthCare 21 Business Coalition
• IBM
• Indiana Employers Quality Health Alliance
• Intel
• Iowa Health Buyers Alliance
• Memphis Business Group on Health
• Midwest Business Group on Health
• National Business Coalition on Health
• National Rural Electric Cooperative Association
• 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:

• Leapfrog's press release on never events, as issued on November 15, 2006
• Sample hospital policy, as it will appear on Leapfrog’s 2007 Hospital Quality and Safety Survey
• Leapfrog's Fact Sheet on Never Events
• FAQs
• Click here to sign on to our policy or to request additional information.