The Leapfrog Group Issues Call for Hospitals to Commit to New Policy on Health Care “Never Events”

November 15, 2006

Today, the National Quality Forum’s newly revised list of 28 Serious Reportable Events (sometimes called “never events” -- medical errors that should never happen to a patient) became final. Also today, The Leapfrog Group issued a call to hospitals to commit to its new Never Events policy which includes apologizing to the injured patient. Hospitals that adopt the policy will be given public recognition through the 2007 Leapfrog Hospital Quality and Safety Survey, a well-known yardstick of a hospital’s quality and safety.

Never events are rare medical errors such as surgery performed on the wrong body part, leaving a foreign object inside a patient after surgery, or an infant discharged to the wrong person. They are clearly identifiable, largely preventable, and serious in their consequences. View the full NQF list here. In May, the Centers for Medicare & Medicaid Services (CMS) announced its intention to work with Congress, hospitals and other health care organizations to reduce payments for care during which a never event occurred and to provide more information to the public about when such events occur.

Leapfrog is taking the next step by giving public recognition to hospitals that agree certain steps should be taken whenever a serious reportable adverse event occurs in their facility. To create an environment where never events are dealt with properly, The Leapfrog Group and its members are working with hospitals, health plans and consumer advocacy groups in the following ways:

  • Through the 2007 Leapfrog Hospital Quality and Safety Survey, hospitals will be given the opportunity to receive public recognition for agreeing to do the following if a “never event” occurs within their facility:
    • Apologize to the patient and/or family affected by the never event.
    • Report the event to at least one reporting program: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO); a state reporting program; or a Patient Safety Organization (e.g., Maryland Patient Safety Center).
    • Perform a root cause analysis, consistent with the chosen reporting program.
    • Waive all costs directly related to the never event and refrain from seeking reimbursement from the patient or a third party payer.
  • National and local consumer advocacy groups through the National Partnership for Women and Families are working with Leapfrog to educate consumers about never events and how hospitals can take steps to prevent them by implementing quality and safety processes.
  • Health plans are also partnering with Leapfrog to encourage the hospitals with which they contract to adopt the Leapfrog never events policy. (Last year, Minnesota’s HealthPartners led the way by initiating a policy that requires contracted hospitals to report, address, and refrain from billing for costs related to never events.)

“We are making improvement real for hospitals by providing a tool to address never events correctly, and making it real for consumers by showing them which hospitals not only take steps to prevent medical errors but do the right thing if they do occur,” commented Catherine Eikel, Director of Programs, The Leapfrog Group. Janet Corrigan, president of the National Quality Forum, praised The Leapfrog Group for recognizing hospitals that participate in safety reporting and improvement efforts and added, "Health care will only become safer if we learn from our mistakes."

"Never events are a symptom of a health care system that is broken and unresponsive," said National Partnership for Women & Families President Debra L. Ness. "We look forward to working with employers to ensure that patients never have to bear the financial costs associated with never events, and to working with policy makers and consumers to prevent never events altogether."

"We encourage our contracted network hospitals to support The Leapfrog Group’s Never Events initiative and commend their ongoing commitment to enhancing the safety of the people in their care," said Charles M. Cutler, M.D., Aetna chief medical director, National Businesses. Aetna is the first health plan to support Leapfrog’s new policy. The following employers and employer groups have also declared their commitment:

  • Caterpillar Inc.
  • Community Health Foundation of Western and Central New York
  • GM
  • Hannaford Brothers
  • Health Policy Corporation of Iowa
  • HealthCare 21 Business Coalition
  • IBM
  • Intel
  • 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


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