Study: One in five hospitals don't have a plan for never events

Accreditation Insider, June 14, 2016

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Despite their name, “never events” such as wrong-site surgeries, retained surgical objects, or deaths or injuries due to patient falls still occur with alarming frequency in U.S. facilities and hospitals. Wrong-site surgery occurs in an estimated one out of 100,000 procedures, and doctors or staff leave a foreign object inside a patient in an estimated one out of 10,000 procedures. In light of this, The Leapfrog Group recommends facilities have a “post-never event policy” that contains the following five elements:

1.    Apologize to the patient and/or family
2.    Waive the costs directly related to the event
3.    Report the event within 10 days to an outside agency (The Joint Commission, a state reporting program, or patient safety organization)
4.    Perform a root cause analysis on the event
5.    Give a copy of the policy to the patients, patients’ family, or payers on request.

That said, a new study by the Leapfrog Group has found that 20% of facilities don’t have policies that meet all five requirements. Furthermore, adoption of never events policies has plateaued over the last three years, with 79% adoption in 2012 and 80% adoption in 2015.

“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,” said Leah Binder, president and CEO of Leapfrog, in a press release. “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. We should see 100% of hospitals with the Leapfrog policy.”

Never event policy rates also greatly varied by state. Compliance was greatest in Washington, Maine, and Massachusetts at 100%, with eight other states achieving at least 90% compliance. However, seven states had fewer than 60% of compliant hospitals and only 10% of hospitals met the standard in Arizona. 

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