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The Leapfrog Group Statement on "Never Events" in Health Care May 18, 2006 In testimony before the Senate Committee on Finance on May 17, CMS Administrator Mark McClellan, stated that CMS wants to eliminate payments for “never events.” “Never events” occur when a patient experiences a negative consequence of care that results in unintended injury, illness or death. The Leapfrog Group strongly supports CMS’ position on never events. “A never event occurs when there is an inexcusable failure in the delivery of health care services,” stated Suzanne Delbanco, CEO, The Leapfrog Group. “The Leapfrog Group’s mission is to reduce preventable medical mistakes and improve the quality and affordability of health care. Paying for never events runs directly contrary to these aims.” The Leapfrog Group is exploring how to provide support to its members who are interested in ensuring that their employees do not get billed for such an event and who do not wish to reimburse for these events themselves. In 2002, the National Quality Forum defined 27 events that should never occur within a health care facility. There are six types of never events: surgical events (e.g., surgery being performed on the wrong patient), product or device events (e.g., using contaminated drugs), patient protection events (e.g., an infant discharged to the wrong person), care management events (e.g., a medication error), environmental events (e.g., electric shock or burn), and criminal events (e.g., sexual assault of a patient). The NQF’s report recommends a national state-based event reporting system to improve the quality of patient care. To date, a little more than half of U.S. states have some version of a reporting system for never events. Contact: Kat Song, Director of Communications (202-292-6707), ksong@leapfroggroup.org # # # |