Home E-Weekly June 28, 2016

What to Do in the Event of a Never Event

Published: June 27, 2016

Much has been written about how to prevent such never events as wrong-site surgery and retained objects, but how are you supposed to respond should one occur at your facility?

The Leapfrog Group, a national advocacy group dedicated to improving healthcare safety, developed a best practice for responding to serious and avoidable never events, which includes the following recommendations:

  • Apologize to patients and their families, to rebuild trust and lessen the likelihood of being sued.
  • Report the event to an outside agency, such as the Joint Commission or National Quality Forum, within 10 days to promote the uniform and public reporting that's needed to improve universal safety efforts.
  • Perform a root cause analysis to determine why the error occurred and how it could be prevented in the future.
  • Waive the costs of care related to the event for the patient and insurer.
  • Make your facility's policy on responding to never events available to patients and insurers to ensure transparency in error reporting.

In its annual survey of U.S. hospitals, Leapfrog asks if facilities use this best practice response when things go seriously wrong. In 2007, the first year Leapfrog asked the question, 53% of hospitals reported having implemented its recommended response protocol. Last year, 80% of hospitals said they followed the protocol. Every reporting hospital in Maine, Massachusetts and Washington met the standard, but only 10% of Arizona's hospitals were compliant.

Leapfrog says the percentage of hospitals with protocols in place has plateaued at 80% since 2012, meaning 1 in 5 facilities fall short of the optimal response to never events. The organization says more reporting transparency is needed to create national benchmarks of safety that ultimately lead to improved policies that protect patients from harm.

Daniel Cook

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