Time to Recommit to Preventing "Never Events"

November 11, 2010

Statement from CEO Leah Binder on Dr. Ring's story in the New England Journal of Medicine

The Leapfrog Group deeply commends Dr. David Ring from Massachusetts General Hospital for his candid, courageous and moving account in the latest issue of the New England Journal of Medicine of performing an incorrect surgical procedure on a patient's hand. "Never Events" like this are, first and foremost, devastating for the patient and family, but also for the doctors and nurses who made the error. All hospitals must take the boldest action possible to prevent these events from ever occurring.

The term "Never Events" has been characterized by some as overreaching, and recently there have been efforts to end its use. But Leapfrog believes the public deserves reassurance that hospitals will work unceasingly to prevent all errors. "Never Events" captures that resolve.

Leapfrog's members—employers and large purchasers of health benefits—issued the first national policy on "Never Events" in 2006. We continue to monitor compliance by hospitals and health plans.

In 2009, more than two-thirds of the over 1,200 hospitals that participate in Leapfrog's national hospital survey reported adopting Leapfrog's robust policy. Hundreds of employers and most health plans have also committed to some form of Leapfrog's Never Events policy, which calls for hospitals to:

  • Apologize to the patient and/or family affected by the never event
  • Report the event to at least one of the following agencies: The Joint Commission; state reporting program for medical errors; or a Patient Safety Organization
  • Agree to perform a root cause analysis, consistent with instructions from the chosen reporting agency
  • Waive all costs directly related to a serious reportable adverse event
  • Make a copy of the policy available to patients and payers upon request

Massachusetts General Hospital has consistently performed well on the Leapfrog Hospital Survey and has internal policies consistent with Leapfrog's never events policy. Dr. Ring's story would suggest that they indeed responded appropriately. All hospitals should commit to a similar level of respect for the patient, to transparency, and to eliminating never events.


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