Never Events Management

How did Leapfrog elevate Never Events to a national priority?

A Never Event is a medical error that should never happen, such as an object left inside a patient after surgery or the transfusion of the wrong blood type. To define Never Events, Leapfrog has adopted the National Quality Forum's list of Serious Reportable Events

Hospitals are asked to report on their adoption of Leapfrog's Never Events policy, which includes the the following actions that must be taken if a Never Event occurs: 

  1. Apologize to the patient and family 
  2. Waive all costs directly related to the event
  3. Report the event to an external agency within 15 business days
  4. Conduct a root-cause analysis of how and why the event occurred
  5. Interview the patient and family, if they are willing and able, to gather evidence for the root cause analysis
  6. Inform the patient and family of the action(s) that the hospital will take to prevent future recurrences of similar events based on the findings from the root cause analysis
  7. Have a protocol in place to support for caregivers involved in the event, and make that protocol known to all caregivers and affiliated clinicians
  8. Perform an annual review to ensure compliance with each element of Leapfrog’s Never Events Policy for each Never Event that occurred
  9. Make a copy of this policy available to patients and families

View Leapfrog Hospital Survey Results here.

Fact sheet on Never Events evidence, measure, and standards

 

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