July 3, 2019

1 in 4 hospitals aren’t properly handling 'never events,' says Leapfrog

Daily Briefing

    Roughly one in four hospitals do not meet the Leapfrog Group's standard for appropriately responding to a "never event," according to a Leapfrog report released Thursday.

    Why nurses are key to preventing never events


    The report looks at how hospitals respond to 29 events that the National Quality Forum defines as "serious reportable events that should never happen," such as performing surgery in the wrong location and patients dying from a medication error.

    These so-called "never events" do not occur often, but when they happen, they tend to be fatal, according to Modern Healthcare

    Report details

    For the latest report, Leapfrog looked at responses from its 2018 Leapfrog Hospital Survey to determine how often hospitals complied with the group's never events policy. When a never event occurs, Leapfrog group's policy states hospitals should take nine actions:

    1. Apologize to the patient;
    2. Report the event;
    3. Conduct a root-cause analysis;
    4. Waive costs related directly to the event;
    5. Give patients and payors a copy of what happened, upon request;
    6. Involve patients and families in the root cause analysis when they're willing and able;
    7. Inform the patient and family of the hospital's plan to prevent future errors of this nature;
    8. Have a protocol to support caregivers involved in the incident; and
    9. Complete an annual review to ensure compliance with the Leapfrog policy every time a never event occurs.

    Key findings

    Leapfrog found that 74.5% of the more than 2,000 hospitals that participated in the 2018 Leapfrog Hospital Survey complied with all nine steps in the never event policy.

    Leapfrog found that rural hospitals were less likely than urban hospitals to be in compliance with the policy. Specifically, Leapfrog found that 64% of rural hospitals complied with the never events policy, compared with 77% of urban hospitals.

    Leapfrog CEO Leah Binder noted that in 2017 Leapfrog amended the list to include steps six through nine, and that prior to the change, hospital compliance with organization's five-step policy had been around 80%. She said that the additional steps could explain the dip in compliance rates for 2018.

    "We have 75% (compliance), so clearly there is a great effort in hospital leadership, but at the same time it's not enough. We need 100%. That is the goal," Binder said (Castellucci, Modern Healthcare, 6/28; Leapfrog report, accessed 7/1; Leapfrog release, 6/27; Reed, Fierce Healthcare, 7/1).


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