One in 5 US Hospitals Fail to Adopt "Never Events" Policies

A new analysis by Castlight Health based on data from the Leapfrog Group’s 2015 Hospital Survey shows that one in 5 US hospitals have failed to adopt a “never events” policy and have not met benchmarks set by Leapfrog for managing never events.

Despite their name, never events—incidents such as when objects are left inside patients after surgery, deaths from medication errors, deaths or serious injuries from falls, and surgeries performed on the wrong parts of patients’ bodies—continue to occur, and when they do, hospitals should take a proactive stance on managing these events and have a policy in place to follow best practice standards for managing a response:

• Apologize to the patient and/or family
• Report the event to an outside agency within 10 days of becoming aware the event occurred
• Perform a root-cause analysis,
• Waive costs directly related to the Never Event, and
• Make a copy of the policy available to patients, patients’ family members, and payers upon request.

This report from Castlight Health is the fourth in a series of reports the company prepares based on the annual Leapfrog Hospital Survey. In 2015, a record 1750 US hospitals submitted a survey, representing 46% of hospitals nationwide and 60% of US hospital beds.

The Leapfrog Group’s 2015 survey of hospitals found that 80% of reporting hospitals met Leapfrog’s standard for never event management. Therefore, one in 5 reporting hospitals continues to lack a never events policy that conforms to all criteria in Leapfrog’s standard. Unfortunately, information on never events is unavailable for hospitals that decline to report to the Leapfrog Hospital Survey.

The 2015 analysis found that hospitals’ adoption of Never Event policies varies by state. The percentage of hospitals meeting Leapfrog’s standard was highest in Maine, Massachusetts, and Washington, where 100% of hospitals reporting in those states met the standard. Eight other states had at least 90% of hospitals meeting the standard. But in Arizona, only 10% of hospitals met the standard. Seven other states also had fewer than 60% of hospitals meeting the standard.

The 2015 Leapfrog hospital survey also found that although adoption of never events policy standards surged between 2007 and 2011, it has plateaued around 79% to 80% since 2012. There has also been an increase in the proportion of hospitals that respond to the Leapfrog survey but decline to report their policy on never events: it was around 2% for the first several years of surveying the topic of never events but has increased to approximately 7% in the 2014 and 2015 surveys.

Finally, the new report notes that wrong-site surgery occurs in about 1 in 100,000 procedures and physicians or staff leave a foreign object inside a patient in an estimated 1 of 10,000 procedures. While any given patient has a very low risk of experiencing a never event, those who do can risk serious injury or death as a consequence. More transparency and quality improvement are needed, the Castlight report recommends.

“How a hospital responds to Never Event is a critical aspect of patient safety,” said Kristin Torres Mowat, senior vice president of plan development and data operations at Castlight Health. “Hospitals are accountable for the care patients receive during their stay.”