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What to do after a ‘Never Event’

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According to a new report by Leapfrog, one in five hospitals don’t have a good system for dealing with hospital events that should never happen, such as wrong-site surgeries, objects left inside patients after surgery, deaths from medication errors or death or serious injuries from falls.

Leapfrog says that the response to such “Never Events” should include:

  • “Apologizing to the patient and/or family.”
  • Reporting the event to an outside agency “within 10 days of becoming aware that the event has occurred.”
  • “Performing a root-cause analysis. To identify the cause of the error and prevent future occurrences, hospitals must formally investigate the circumstances contributing to a Never Event. This requirement is in line with other national policies such as the one specified by The Joint Commission’s hospital accreditation program.”
  • Waiving “costs directly related to the Never Event. Hospitals must review these cases to determine which costs are attributable to the Never Event, and waive those costs so that neither the patient nor payer is billed.’’
  • “Making a copy of the policy available to patients, patients’ family members, and payers upon request.”


To read the full report, please hit this link.



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