Responding to Never Events

Although rare, some medical errors are so serious that experts agree they should never happen to a patient. These kinds of errors include leaving an object inside a patient’s body after surgery or operating on the wrong body part. This measure assesses whether the surgery has a policy in place that includes the following nine (9) actions that must happen if a never events occurs:  

1. Apologize to the patient and family
2. Waive all costs directly related to the event
3. Report the event to an external agency
4. Conduct a root-cause analysis of how and why the event occurred
5. Interview patients and families, who are willing and able, to gather evidence for the root cause analysis
6. Inform the patient and family of the action(s) that the hospital will take to prevent future recurrences of similar events based on the findings from the root cause analysis
7. Have a protocol in place to provide support for caregivers involved in Never Events, and make that protocol known to all caregivers and affiliated clinicians
8. Perform an annual review to ensure compliance with each element of Leapfrog’s Never Events Policy for each never event that occurred
9. Make a copy of this policy available to patients upon request

Reporting Period

• 2024

Patients Included in the Measure

• Outpatients (Patients who are admitted and discharged on the same day)
• Adults and Children