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 or the transfer of a wrong type of blood. Leapfrog utilizes the National Quality Forum's list of serious reportable events in asking hospitals to adopt a Never Events policy.
Leapfrog's Never Events policy now asks hospitals to commit to the following basic acts if a Never Event does occur:
- apologize to the patient and family,
- waive all costs directly related to the event,
- report the event to an external agency,
- conduct a root-cause analysis of how and why the event occurred,
- interview patients and families, who are willing and able, to gather evidence for the root cause analysis,
- 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,
- have a protocol in place to provide support for caregivers involved in never events, and make that protocol known to all caregivers and affiliated clinicians,
- perform an annual review to ensure compliance with each element of Leapfrog’s Never Events Policy for each Never Event that occurred.
- make a copy of this policy available to patients
All hospitals should abide by these basic pillars of respect in treating those affected by a Never Event. It is publicly reported as Never Events Management on Leapfrog's Hospital Ratings Results page.