HPCI News: One in Five U.S. Hospitals Fail to Adopt Critical "Never Events" Policies

To: Members and Selected Others

A new report shows that one in five U.S. hospitals failed to adopt “Never Events” policy that meets Leapfrog’s standard (which includes such actions as apologizing, waiving all costs, and performing a root-cause analysis). “Never Events” includes incidents such as objects left inside patients after surgery, deaths from medication errors, deaths or serious injuries from falls, and surgeries performed on the wrong parts of patient’s bodies.

This report is the fourth of five Castlight Health reports on the results of the 2015 Leapfrog Hospital Survey. Leapfrog partnered with Castlight, an industry leader in providing tools to aid consumers in their health care decision-making. The series draws on data from the Leapfrog survey of 1,750 U.S. hospitals, representing 60% of the inpatient beds nationwide.

“Never Events are egregious and they truly should never happen”, said Leah Binder, President and CEO of Leapfrog. She added that are the most worrisome hospitals are those that declined to respond to the questions. In Iowa, only three hospitals responded – Allen Hospital in Waterloo, Grinnell Regional Medical Center in Grinnell, and Skiff Medical Center in Newton.

Additional key findings:

  • Adoption of Never Events policies varies by state: The percentage of hospitals meeting Leapfrog’s standard was highest in Washington State, Maine, and Massachusetts, where 100% of hospitals reporting in those states met the standard.
  • Implementation of Never Events policies has plateaued: In the years following the addition of Never Events Management to the Leapfrog Hospital Survey, there was a surge of hospitals meeting the standard, from 53% in 2007 to 79% in 2012. Since then, progress has stalled around 80%.
  • More transparency and quality improvement are needed: While the probability appears low, those affected by Never Events risk serious injury and death.

“How a hospital responds to a Never Event is a critical aspect of patient safety, and hospitals are accountable for the care patients receive during their stay,” according to Castlight Health. “Castlight’s work with The Leapfrog Group helps empower patients with the information needed to make the right choices for their health. A hospital’s clinical quality and safety are critical to enable well-informed decision making and can ultimately lead to improved outcomes for patients,”

Reports on hospital performance can be found at hhttp://www.leapfroggroup.org/ratings-reports/reports-hospital-performance

Paul M. Pietzsch, MPH
HPCI - IHBA Office
4430 Ashley Park Drive
West Des Moines, Iowa 50265
(515) 778-6300

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