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Leapfrog Hospital Quality and Safety Survey
Staff Writers
According to a September 2007 report, just over half of responding hospitals have adopted the new Leapfrog Group Never-Events Policy, which is a list of actions to take whenever a “never-event” – a rare medical error – occurs. By agreeing to this policy, hospitals pledge to:
- Apologize to the patient and/or family affected by the never-event.
- Report the event to at least one of the following agencies: The Joint Commission, a state reporting program for medical errors, a Patient Safety Organization.
- Perform a root cause analysis, consistent with instructions from the chosen reporting agency.
- Waive all costs directly related to the serious reportable adverse event.
The Leapfrog Group follows the National Quality Forum’s (NQF) definition of “never-events”; which includes errors such as surgery performed on the wrong body part or on the wrong patient, leaving a foreign object inside a patient after surgery, and discharging an infant to the wrong person, etc.
Is this policy reasonable or unreasonable, in your estimation?
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Filed under: Health Law & Policy | Tagged: Health Law & Policy |
The Leading Business Education Network for Doctors, Financial Advisors and Health Industry Consultants 
I understand that the Vermont Association of Hospitals and Health Systems has become the third group to officially declare that its members won’t bill patients or insurance companies for a core set of adverse events.
The association has agreed not to bill for eight serious events, drawn from a list of 28 “never-events” developed by the National Quality Forum [NQF]. Vermont hospitals now won’t bill for air embolism-associated injury, artificial insemination/wrong donor, incompatible blood-associated injury, med error injury, retention of foreign objects within a patient, wrong-patient and wrong-site surgery and wrong surgical procedure.
So, what about the other 20 N-Es?
Jamie
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Jamie,
Aetna has just announced a new policy under which it will refuse to pay for care related to a group of 28 adverse events, and require medical providers to take a series of reporting and corrective steps to address the errors.
http://www.fiercehealthfinance.com/story/aetna-refuses-payment-never-events-requires-corrective-action/2009-08-26?utm_medium=nl&utm_source=internal
Chase
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Chase and Jamie,
This new report suggests that N-E policies do not save money!
http://www.fiercehealthfinance.com/story/study-medicare-has-saved-virtually-nothing-through-non-payment-policy/2009-09-14?utm_medium=nl&utm_source=internal
Any other thoughts?
Steve
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More on N-Es
Unfortunately, the nation’s hospitals are still failing to protect patients from potentially fatal infections despite years of prevention campaigns. The Health and Human Services Department’s 2009 quality report to Congress found “very little progress” on eliminating hospital-acquired infections and called for “urgent attention.”
As many as 98,000 people a year die from medical errors and preventable infections.
http://www.detnews.com/article/20100414/LIFESTYLE03/4140375/1020/Hospitals-faulted-for-patient-infections/Hospitals-faulted-for-patient-infections#ixzz0l4RGqzE0
Barbara
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Website to Collect Patients’ Views on Adverse Events
Patients who have been the victim of an adverse medical event will now have a new way to share the details of their experiences, according to the Empowered Patient Coalition. The San Francisco-based not-for-profit group, in collaboration with the Austin, Texas-based Consumers Union Safe Patient Project, has released a 40-question online survey that patients can use to report on their perspectives of incidents of medical harm.
The survey prompts respondents to provide the details of the incident including the state where it occurred, the type of provider involved, contributing factors, whether they considered litigation and providers’ response following the event. Patients have the option of submitting the surveys anonymously. Patients can also choose from several checklists to indicate the procedure or treatment that was associated with the adverse event.
For instance, in the section of the survey related to surgical errors or complications, the respondent can check boxes to indicate “wrong-site surgery” or “post-operative complication.” There are also fields to provide details about healthcare-associated infections, falls, adverse medication events and other types of incidents.
Source: Maureen McKinney, Health IT Strategist [4/26/10]
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A Brief History of Never Events
Over the years, multiple lists of adverse medical events that are deemed preventable have been published. CMS released a group of hospital-acquired complications (HACs) that they will no longer pay for. The Joint Commission published its National Patient Safety Goals and implemented it as part of their accreditation process. The National Quality Foundation (NQF) has Serious Reportable Events. All of these have been thrown under the title of “never events,” to the confusion of many.
“In 2003, then-NQF chief executor officer Ken Kaiser coined the term ‘never events’ to describe things that should just never happen in healthcare,” says Peter Angood, MD, the foundation’s senior advisor for patient safety. “Although there is some overlap, each of these lists was developed by different entities for different reasons, using different criteria for inclusion. NQF now uses the term Serious Reportable Events and regularly updates its list to include the newest evidence.”
Efforts to harmonize the language and criteria across the various organizations have been made, and some believe a coordinated list will alleviate the confusion brought about by various lists. “While there have been many types of initiatives taken over the last decade or so, the fact remains that ongoing improvements are still required for patient safety in patient care, as well as the efficiency of that care,” Dr. Angood says. “Efforts around reportable events, no matter who they are reported to, are one component in spurring safer, higher-quality care.”
Source: http://www.the-hospitalist.org/details/article/574151/HospitalAcquired_Conditions__The_Hospitalist.html
CMS’ List of Hospital-Acquired Conditions
• Foreign object retained after surgery;
• Air embolism;
• Pressure ulcers;
• Blood incompatibility;
• Trauma (fracture-dislocations, intracranial injury, crushs, burns, electric shock);
• Catheter-associated UTIs;
• Vascular catheter-associated infection;
• Manifestations of poor blood-sugar control;
• Surgical-site infection following coronary artery bypass surgery;
• Surgical-site infection following orthopedic procedures;
• Surgical-site infection following bariatric surgery for obesity;
• DVT and PE following orthopedic procedures; and
• Ventilator-associated pneumonia.
Source: Centers for Medicare and Medicaid Services
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The Ultimate Never-Event
USC University Hospital in LA shut down its kidney transplant program last month after a kidney was accidentally transplanted into the wrong patient.
http://www.bing.com/news/search?q=kidney+mix+up+&qpvt=kidney+mix+up+&FORM=EWRE
The ultimate NE? Nay! That would be a wrong head transplant.
Calvin
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Agencies consider new kidney transplant rules
http://www.msnbc.msn.com/id/41787636/ns/health-health_care
This concept would match younger organs with younger patients, and vice versa.
Death panels?
Samantha
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Medical Errors Continue?
In a new study, researchers reviewed the medical records for 795 patients at three large U.S. hospitals that had “well-established operational patient safety programs.” Using the Global Trigger Tool, they looked for “triggers” to see whether there had been an adverse event, and how severe it might have been.
They detected 354 adverse events among the patients — 10 times more than other methods in use. In fact, overall, adverse events occurred in 33.2% of admissions.
http://www.latimes.com/health/boostershots/la-heb-hospital-errors-20110407,0,1083235.story
Shameful!
Brian
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Update on Never Events
http://community.the-hospitalist.org/blogs/wachters_world/archive/2011/06/29/never-say-never-events.aspx
Hope Rachel Hetico RN MHA
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Woman’s face catches on fire during surgery
It was supposed to be a routine outpatient surgery to remove some head growths. But, something went horribly wrong during the morning out-patient procedure and a flash fire seared the patient’s face and neck.
http://vitals.msnbc.msn.com/_news/2011/12/02/9168719-womans-face-catches-on-fire-during-surgery
So, is this a NE?
Terry
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Bloody Red
Federal health officials just fined the American Red Cross nearly $9.6 million for sloppy and unsafe blood management practices, the second multi-million-dollar penalty levied against the agency in the last two years.
http://vitals.msnbc.msn.com/_news/2012/01/16/10168484-fda-fines-red-cross-nearly-96-million-for-blood-safety-lapses
Sheldon
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Some Docs Hesitant to Disclose Errors
A new study finds that while a majority of doctors believe they should disclose significant medical errors to patients, some won’t for fear of being sued. The results appear in the February issue of the journal Health Affairs. Researchers conducted the poll in 2009, and 1,891 doctors answered anonymously.
The results revealed that 66% completely agreed that they should fully disclose all significant medical errors to patients. The survey also reports that 89% of doctors did not tell a patient something untrue over the past year. But when asked if they have not disclosed a mistake because of worries that they would be sued, 20% replied that they have withheld information over the past year.
Source: Ashok Selvam, Modern Healthcare [2/8/12]
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Surgeons left 4,857 objects in patients over the past two decades
They’re known in medicine as the ‘never’ events that should never happen: ie., Leaving an object in the patient, or operating on the wrong body part.
http://www.washingtonpost.com/blogs/wonkblog/wp/2012/12/20/surgeons-left-4857-objects-in-patients-over-the-past-two-decades/
Turns out, however, these never events actually happen hundreds of times each year.
Dr. David Edward Marcinko MBA
http://www.CertifiedMedicalPlanner.org
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Medical Ops!
Here are my steps to deal with a medical error that are relatively straightforward:
1. Tell the patient and family ASAP in a non-judgmental and guilt-free manner.
2. Notify any needed medical consultants.
3. Document the error and report it to the hospital safety committee.
4. Notify your malpractice insurer.
5. Review your internal policies and procedures to reduce future events.
6. Reduce your billings or accept insurance as payment in full, and request consulting colleagues and hospital to do same. Remember, there may come a time when you are asked to return-in-kind.
Be a mensch!
Dr. David Edward Marcinko MBA
[Editor-in-Chief]
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Wrong Patient Brain Surgery
Taking wrong side surgery to the next level.
http://www.msn.com/en-us/health/medical/doctors-protest-after-wrong-patient-gets-brain-surgery/ar-BBJTAdk?li=BBnbfcL
Dr. David E. Marcinko MBA
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DENTAL NEVER-EVENTS
A list of dental ‘never events’ has been published by researchers led by the University of Edinburgh.
http://www.dentistry.co.uk/2018/05/15/list-dental-never-events-published/
Darrell K. Pruitt DDS
via Ann Miller RN MHA
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Patient Dropped on Floor and Dies
https://www.msn.com/en-us/news/world/woman-dies-after-being-dropped-on-floor-following-surgery/ar-AAKuouW?li=BBorjTa
Lily
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