Never Again

Following smaller regional efforts to eliminate, or at least reduce, the occurrence of so-called "never events"-critical errors such as performing the wrong surgery on a patient or sending a newborn home with the wrong parents-the employer-backed Leapfrog Group is pushing an effort to develop a new national policy for addressing such events and taking steps to ensure they are not repeated."We are hoping that through a policy like this there will be more reporting of never events to the appropriate entities-such as the Joint Commission or a state reporting system; not for public reporting, but so that the hospital can go through the process and do a root-cause analysis and improve for the next time," says Catherine Eikel, director of programs for the Washington, D.C.-based group. Eikel is referring to a new addition to the organization's 2007 Hospital Quality and Patient Safety Survey that asks hospitals to commit to four key policies for addressing these serious reportable events: apologizing to the patient or family affected, reporting the event to at least one reporting program, performing a root-cause analysis of the event, and waiving all costs directly related to the never event. Hospitals that commit to following these principles will receive recognition on the group's Web site.George Isham, M.D., chief health officer for Bloomington, Minn.-based HealthPartners, says he's encouraged by the Leapfrog effort, which builds on a policy HealthPartners, a nonprofit provider of healthcare services and health plan financing and administration in five states, has had in place for more than two years. "I think the Leapfrog Group has improved on our thinking by the way they've formulated this policy," he says. "They've put it together in a package to give hospitals a very proactive and very appropriate way to deal with a serious mistake or error."In practice, Isham says the Minnesota effort has come off with few conflicts. "When these situations have occurred we've cooperated with the hospital and they with us," he says. "Where people get concerned is when you have theoretical conversation around the issue-then the concern comes up that if we're making this kind of policy to not pay for these serious never events then that might lead us to not pay for other things."Both Isham and Eikel, however, say there are no plans for expanding the no-payment stance to cover other policies or procedures. -Brad Cain