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AAOS Now

Published 7/1/2011
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Leah Binder

Four principles of “never events”

Phrase coined by The Leapfrog Group must become a reality

Lewis Blackman, an energetic and promising 15-year-old from South Carolina, underwent surgery to correct a common congenital deformity in his chest. The surgery was successful, but during his postoperative care, Lewis experienced an adverse reaction to an anti-inflammatory drug. Despite pleadings from his mother and obvious signs of deterioration, Lewis’ caregivers did not change his medication.

As it turned out, Lewis received a total of 17 adult doses of the medication. After bleeding internally for more than 30 hours, Lewis passed away at the hospital on Nov. 6, 2000. Lewis’ death is yet one more tragic case of a “serious reportable event (SRE) that should never happen,” as defined by the National Quality Forum (NQF). Lewis’ story, as retold in Dr. Sanjaya Kumar’s powerful book Fatal Care, is a reminder of what is at stake in our national efforts to improve safety and quality in health care.

For years, events like these have been kept behind closed doors, locked in by scared and emotionally damaged clinicians, angry and saddened patients, and long, drawn-out lawsuits. In 2006, The Leapfrog Group, representing the nation’s largest purchasers of healthcare benefits, unveiled a set of principles for hospitals focused on the NQF’s list of 28 events.

In doing so, The Leapfrog Group coined the term “never events.” The Never Events Principles draw on purchasers’ experience with customer service norms in their various industries, from airlines to automakers to hospitality.

Never events are incidents so awful that most people cannot hear about them without wincing. These events include the removal of the wrong limb in surgery, serious medication errors, transfusion of the wrong blood type, sexual assaults on patients, discharge of infants to the wrong parent, and more.

Four simple principles
Leapfrog now asks hospitals, through the annual Leapfrog Hospital Survey, to adhere to four simple principles:

  1. Apologize to the patient.
  2. Report the event to state reporting agencies or the Joint Commission.
  3. Do a root cause analysis.
  4. Waive all fees related to the event.

In 2009, 68 percent of hospitals reporting to the Leapfrog Hospital Survey adopted these four principles. Encouraging as this may be, one third of reporting hospitals still do not have the policy in place.

Why do some hospitals object to adopting a never events policy? Some worry about lawsuits if they apologize to the patient, even though studies show apologies vastly reduce the odds of lawsuits. Others are concerned that some events are flukes that may not have been preventable, so why should the hospital have to bear the cost?

This concern about whether some SREs may not be entirely preventable in each and every circumstance is fueling a controversy at the NQF as members revisit the definition of SREs. Unfortunately, the debate at NQF pivots around how preventable the incident is, not on how catastrophic it would be for the patient.

Making it right
Most healthcare purchasers are indignant about never events. They are part of industries where it would be unthinkable to charge the customer for harm experienced under their watch. No airline would charge a passenger for rescue operations after a plane crash, and no grocer would refuse to refund a food item known to have been tainted. Even if the airline or the grocer were not directly responsible for the tragedy, they would apologize and not charge the customer.

When Captain Chesley “Sully” Sullenberger safely landed US Airways Flight 1549 in the Hudson River in January 2009, no one knew what caused the crash. That did not stop the exemplary immediate efforts of the captain, the crew, and the airline to put the passengers first. A never events policy would help healthcare providers demonstrate that they put patients first.

Yet health care sometimes plays by different rules. It is likely that Lewis’ family and/or insurance plan was billed for the cost of the medication that killed him, and it is possible no one at the hospital apologized for this terrible tragedy. Leapfrog’s Never Events Principles resonate with purchasers because they insist that health care uphold values fundamental to human decency and core to good business practice.

To the credit of the hospital community, most hospitals agree. But 100 percent of hospitals must agree, and patients like Lewis remind us every day why purchasers aren’t going to stop demanding that they do.

Leah Binder is chief executive officer of The Leapfrog Group. In 2011, The Leapfrog Group will revisit the Never Events Policy to determine what impact the policy has had on hospitals, purchasers, and, most importantly, patients. It will be asking hospitals and providers to share their experiences in implementing this policy. For more information about The Leapfrog Group’s Never Events Policy, or to share your hospital’s experience in implementing the policy, contact Missy Danforth, director of communications & membership, at mdanforth@leapfroggroup.org