Hospitals voluntarily enact Leapfrog Group's policy on "never events"

February 1, 2008

More than 650 hospitals have pledged to adopt the Leapfrog Group's policy on "never events"-rare medical errors that should never happen to a patient.

MORE THAN 650 HOSPITALS have pledged to adopt the Leapfrog Group's policy on "never events"-rare medical errors that should never happen to a patient.

A never event (also known as a serious reportable adverse event) is an error in medical care that is clearly identifiable, preventable and serious in its consequences for patients, and indicates a real problem in the safety and credibility of a healthcare facility, according to the National Quality Forum (NQF).

NQF has adopted a list of 28 never events. Examples of a never event include surgery on the wrong body part, a foreign object left in a patient after surgery, mismatched blood transfusion, major medication error and preventable post-operative deaths.

One study, reviewing 18 types of medical events, concluded that medical errors may account for 2.4 million extra hospital days, $9.3 billion in excess charges (for all payers) and 32,600 deaths, according to the Leapfrog Group. Another study concluded that never events add significantly to Medicare hospital payments, ranging from an average of an additional $700 per case to treat decubitus ulcers to $9,000 per case to treat postoperative sepsis, according to the Centers for Medicare & Medicaid Services (CMS).

The Leapfrog Group follows the NQF definition of a never event. Its policy mandates that hospitals: waive all costs connected to a never event; apologize to the patient and/or family; report the event to at least one agency (the Joint Commission, a state reporting program for medical errors or a patient safety organization); and perform a root cause analysis consistent with instructions from the chosen reporting agency.

"The motivation behind our policy is to provide a tool for hospitals to handle a rare but ubiquitous problem," says Rachel Weissburg, Leapfrog Group program associate.

PLANS, STATES SPEAK UP

While the Leapfrog Group policy is voluntary, many states are adopting regulations and laws that compel hospitals to adopt such a policy.

At least 13 states use the NQF list in whole or in part as the basis for their public reporting systems, although states are under no obligation to let NQF know whether they adopt or adapt the list.

In 2005, Minnesota became the first state to require the public reporting of NQF's list of never events. This followed a law implemented in 2004 that requires hospitals to report never events to the state Department of Health, which are publicly reported annually.

HealthPartners, based in Bloomington, Minn., built on this legislation by implementing a policy that stops payments to hospitals for never events. The policy, which was implemented in 2005, also prohibits hospitals from billing members for a never event.

The policy also requires hospitals to comply with the state's reporting act, including the investigation of a never event, reporting its underlying causes and taking action.

HealthPartners contracts with virtually every hospital in the state of Minnesota.

"Our policy builds on the state's policy," says Babett Apland, senior vice president, health and care management, for HealthPartners. "With the leadership of Minnesota in creating a [reporting] policy, we saw an opportunity to continue that leadership relative to payment policy."

Apland says that HealthPartners' policy brings a consistent approach to a never events policy.

"Our sense was that even before our policy went into effect, some hospitals were systematically stopping billing when a never event happened," she says. "But it wasn't clear that this was consistent."

There is no bonus or incentive for hospitals to adhere to the policy.