September 29, 2007 | Mark Paradies

Leapfrog Group Reports 52% of Hospitals Responding to its Survey Say They Will Comply with the “Never Event” Pledge

What is the “Never Event” Pledge?

If a hospital agrees to the Never Event Pledge, the hospital pledges to:

Apologize to the patient and/or family affected by the never event;
Report the event to at least one of the following agencies: the Joint Commission, a state
reporting program for medical errors, a Patient Safety Organization;
• Perform a root cause analysis, consistent with instructions from the chosen reporting
agency; and,
Waive all costs directly related to the serious reportable adverse event.

Since this seems very reasonable, it seems surprising that more hospitals have not agreed to the pledge.

For the complete press release from the Leapfrog Group about this survey, click on the link below.


HALF OF US HOSPITALS REPORTING TO LEAPFROG
SAY THEY WON’T BILL FOR A “NEVER EVENT”

Washington DC – Just over half (52%) of hospitals responding to the Leapfrog Hospital Quality  and Safety Survey – a national hospital quality rating tool – indicate they have adopted the Leapfrog Never Events policy, a list of actions they pledge to take whenever a “never event” – a  rare medical error that should never happen to a patient – occurs.

This year, 1,285 hospitals reported for the first time on their adherence to the Leapfrog Never  Events policy. By agreeing to this policy, hospitals pledge to:

• Apologize to the patient and/or family affected by the never event;
• Report the event to at least one of the following agencies: the Joint Commission, a state
reporting program for medical errors, a Patient Safety Organization;
• Perform a root cause analysis, consistent with instructions from the chosen reporting
agency; and,
• Waive all costs directly related to the serious reportable adverse event.

Leapfrog follows the National Quality Forum’s definition of never events. The NQF’s list of 28
“serious reportable events” includes errors such as surgery performed on the wrong body part  or on the wrong patient, leaving a foreign object inside a patient after surgery, and discharging  an infant to the wrong person.

“Through the Leapfrog Hospital Quality and Safety Survey, we give public recognition to
hospitals that are willing to take all the right steps in the rare instance that a never event occurs  in their facility,” stated Suzanne Delbanco, CEO, The Leapfrog Group. “The hospitals who agree to our Never Events policy are also helping us to pioneer ways to tie payments for care to quality.”

An analysis of Survey results seems to show that smaller hospitals have a slight edge over  larger ones in the rate of adoption of the Leapfrog Never Events policy. The following percentages of hospitals responded that they agree to the policy:

• 59% of small hospitals (1-100 beds)
• 53% of medium hospitals (101-250 beds)
• 48% of large hospitals (251+ beds)

Hospitals that agree to the Never Events policy are twice as likely to have scored full points on the Leapfrog Safe Practices Score (SPS) than those hospitals that have not adopted the policy.

The Safe Practices Score – an indicator of how committed a hospital is to maintaining high
levels of quality and safety – asks hospitals how well they implement 27 of the NQF’s Safe Practices. Thirty-three percent of hospitals who commit to the Leapfrog Never Events policy have scored full points on the SPS; only 17% of those who did not commit to the policy scored full points on the SPS.

“By asking hospitals to commit to its Never Events policy, Leapfrog encourages hospitals to
disclose their mistakes, take aggressive steps to learn from their mistakes, and make every
effort to prevent them from happening again. This gives American consumers the kind of assurance they are seeking from the health care system,” said Debra Ness, President, National Partnership for Women and Families.

The Leapfrog Group (www.leapfroggroup.org). On behalf of the millions of Americans for whom many of the nation’s largest corporations and public agencies buy health benefits, The Leapfrog Group aims to use its members’ collective leverage to initiate breakthrough
improvements in the safety, quality, and affordability of health care for Americans. The Leapfrog Group was founded in November 2000 by the Business Roundtable and is supported by its members, the Robert Wood Johnson Foundation, The Commonwealth Fund, the Agency for Healthcare Research and Quality and other sources.

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