One in 5 hospitals fall short on 'never events'

Twenty percent of U.S. hospitals don't have a policy for "never events"--serious medical errors or adverse events that should never happen to a patients--that meet a national patient safety watchdog's standards, according to a new report.

Never events include wrong-site surgeries, objects left inside patients after surgery, deaths from medication errors or death or serious injuries from falls. 

Leapfrog's standards for a response to never events include a full apology; a report to the Joint Commission, a state reporting program or a patient safety organization; a full root cause analysis; waiver of all costs to the affected patient; and a copy of the hospital's policy provided on request to patients and payers. 

"Never events are egregious and they truly should never happen, but at the very least if they do happen, we expect hospitals to take the most humane and ethical approach," Leah Binder, president and CEO of Leapfrog, said in the report announcement. "Unfortunately, many hospitals still won't commit to doing the right thing, including apologizing to the patient or family and not charging for the event."

The report found broad variation in compliance by state, with 100 percent of reporting hospitals in Washington, Maine and Massachusetts meeting the standards, compared to only 10 percent in Arizona. "Geographically… more or less the southeast and Midwest have the lowest rates of compliance," Erica Mobley, Leapfrog's director of communications & development, told FierceHealthcare in an exclusive interview.

While it's difficult to know for sure why so many hospitals haven't adopted a compliant policy, Mobley said it's like many worry that such a policy would increase the risk of malpractice suits. However, she said, they shouldn't worry, as research has suggested patients who receive an apology are less likely to sue.

"Most cases patients just want to hear that their providers are sorry," she said. "Hospitals should not let fear of litigation prevent them from adopting this policy." Indeed, a lawsuit-wary "culture of secrecy" often keeps patients out of the loop about their own outcomes, FierceHealthcare previously reported

Hospitals' commitments to meaningful apologies have increased in recent years, with Palo Alto, California's Stanford Hospital adopting protocols similar to those recommended by Leapfrog as well as offering financial settlements as an alternative to lawsuits.

To learn more:
- read the announcement
- here's the report (.pdf)

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