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 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: 

  1. apologize to the patient and family, 
  2. waive all costs directly related to the event,
  3. report the event to an external agency,
  4. conduct a root-cause analysis of how and why the event occurred,
  5. interview patients and families, who 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 provide support for caregivers involved in never events, 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

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.


Fact sheet on Never Events evidence, measure and standards


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