Twenty percent of reporting hospitals lack a policy that conforms to all of the criteria in the Leapfrog group's standard for preventable hospital errors dubbed "never events" the nonprofit agency has found in a newly released report.
Never events were elevated to national attention in 2006 by The National Quality Forum, which published a report defining and listing these hospital errors. Soon after, the Centers for Medicare and Medicaid Services released a statement saying that never events "cause serious injury or death to patients, and result in increased costs to the Medicare program to treat the consequences of the error."
Never event errors include surgery performed on the wrong part of the body (or on the wrong patient altogether); objects left inside a patient after surgery; deaths from medication errors; and death of serious injury from a fall in a hospital. In all, 29 types of events have been classified as never events by the National Quality Forum.
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The data show that hospitals' adoption of never event policies varies by state. The percentage of hospitals meeting Leapfrog's standard was highest in Maine, Massachusetts and Washington, where 100 percent of reporting hospitals met the criteria. Eight other states had at least 90 percent of hospitals meeting that benchmark. But in Arizona, only 10 percent of hospitals met the standard, and seven other states saw fewer than 60 percent of hospitals with adequate policies.
What's more, the implementation of never events policies has plateaued. In 2007, when Leapfrog added never events management to its annual survey, only about 53 percent of hospitals had policies meeting Leapfrog's standard. The rate climbed to almost 80 percent by 2012, but in the four annual surveys since, 79 to 80 percent of hospitals have met the standard.
There has also been an increase in the proportion of hospitals that respond to the Leapfrog survey, but decline to report their policy on never events. That percentage hovered around 2 percent for the first few years of surveying on the topic, but it's been bumped up to around 7 percent in the 2014 and 2015 surveys.
Leapfrog has recommended that hospitals take a number of steps after a never event has occurred. The first is simply to apologize to the patient and/or family, which the group said can rebuild trust and reduce the risk of a malpractice suit.
Further recommendations are to report the event to an outside agency within 10 days of becoming aware that it has occurred; to perform a root-cause analysis, which can help prevent future never events; to waive the costs directly related to the never event so that neither the patient nor payer is billed; and to make a copy of the hospital's policy available to patients, their family members, and payers upon request.