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The Leapfrog Group Releases 2019 Never Events Report

The Leapfrog Group released its 2019 Never Events Report. The report found that one in four participating hospitals do not meet The Leapfrog Group’s standard for handling of serious reportable events that should never happen to a patient (Never Events). The report is based on the findings from the 2018 Leapfrog Hospital Survey, with data voluntarily submitted by more than 2,000 U.S. hospitals.

The report calls attention to official hospital policies for responding to the 29 serious reportable events as identified by The National Quality Forum (NQF). These include errors and accidents that hospitals should always prevent, such as surgery on the wrong body part, foreign objects left in the body after surgery, death from a medication error, and others that stakeholder consensus has defined as always preventable. The Leapfrog standard for hospital policies includes such steps as: an apology to the patient, not charging for the event, a root cause analysis that includes interviews with patients and family, reporting to appropriate officials, implementing a protocol to care for the caregivers involved and making the policy available to patients and payors.

Leapfrog’s Never Events Policy includes nine basic principles for response if a Never Event does occur, which is expanded from five principles first issued in 2007. In 2017, The Leapfrog Group’s expert panel recommended adding four new principles as a result of new evidence and testing of best practices by leading health systems, as well as work by national organizations including the Agency for Healthcare Research and Quality and the National Patient Safety Foundation.

The report also found a distinction between how rural and urban hospitals adopt the Never Events Policy. More hospitals in urban areas (77%) are meeting Leapfrog’s new standard compared to hospitals in rural areas (64%).

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