One in Five U.S. Hospitals Fail to Adopt Crucial “Never Events” Policies

June 9, 2016
Castlight Report Never Events

In 2007, The Leapfrog Group began asking hospitals about their process for handling Never Events – or incidents such as objects left inside patients after surgery, deaths from medication errors, deaths or serious injuries from falls, and surgeries performed on the wrong parts of patients’ bodies. According to a new report released today by Leapfrog and analyzed by Castlight Health, one in five hospitals still fail to adopt a Never Events policy and otherwise do not meet Leapfrog’s standard for Never Events Management.

"If [Never Events] do happen, we expect hospitals to take the most humane and ethical approach."

“Never Events are egregious and they truly should never happen, but at the very least if they do happen, we expect hospitals to take the most humane and ethical approach,” said Leah Binder, president and CEO of Leapfrog. “Unfortunately, many hospitals still won’t commit to doing the right thing, including apologizing to the patient or family and not charging for the event. We should see 100% of hospitals with the Leapfrog policy.”

She added that the most worrisome hospitals are those that decline to respond to the question about whether they have a policy.  


Castlight Report Never Events
SOURCE: Castlight Health analysis

Additional key findings include:

  • Adoption of Never Events policies varies by state: The percentage of hospitals meeting Leapfrog’s standard was highest in Washington, Maine and Massachusetts, where 100% of hospitals reporting in those states met the standard. Alternatively, in Arizona, only 10% of hospitals met the standard.  
  • Implementation of Never Events policies has plateaued:  In the years following the addition of Never Events Management to the Leapfrog Hospital Survey, there was a surge of hospitals meeting the standard. In 2007, only 53% of hospitals met the standard, and by 2012 that rate increased to 79%. Since then, progress has stalled around 80%.
  • More transparency and quality improvement are needed: Wrong-site surgery occurs in an estimated 1 out of 100,000 procedures, and doctors or staff leave a foreign object inside a patient in an estimated 1 out of 10,000 procedures. While the probability appears low, those affected by Never Events risk “serious injury or death,” as stated by the Center for Medicare & Medicaid Services.

"How a hospital responds to a Never Event is a critical aspect of patient safety, and hospitals are accountable for the care patients receive during their stay,” said Kristin Torres Mowat, senior vice president of plan development and data operations at Castlight Health. “Castlight's work with The Leapfrog Group helps empower patients with the information needed to make the right choices for their health.  A hospital’s clinical quality and safety are critical to enable well-informed decision making and can ultimately lead to improved outcomes for patients.”

Today’s report is the fourth in a series of five that examines key quality and safety measures at hospitals nationwide. The series draws on data from the 2015 Leapfrog Hospital Survey of 1,750 U.S. hospitals, representing 60% of the inpatient beds nationwide, with analysis provided by Castlight Health. Previous and future publications in the series can be found here.


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