Quarter of Hospitals Fail to Comply with Medical Errors Policy

About a quarter of hospitals fail to meet the Leapfrog Group’s standards in addressing serious patient harm events should they occur, according to a new report.

The analysis, published Thursday, found 74.5% of the more than 2,000 hospitals that received a patient-safety grade from the Leapfrog Group in 2018 complied with all nine aspects of the group’s never-event policy. Hospital compliance with the standard has hovered at or slightly below 80% since 2014.

“These are fundamental principles in any other industry, but in healthcare it’s not fundamental or else we would have 100% compliance,” said Leah Binder, CEO of the Leapfrog Group. “We have 75% (compliance), so clearly there is a great effort in hospital leadership, but at the same time it’s not enough. We need 100%. That is the goal.”

There are 29 events the National Quality Forum has defined as serious patient-safety errors that should be reported. They are often called never events and include surgery performed on the wrong site or death caused by a medication error. Never events occur rarely, but when they do they are often fatal to the patient.

The Leapfrog Group has included the never-event policy in its survey to hospitals since 2008. It updated the policy in 2017 with four additional actions, bringing the total to nine.

The policy outlines nine actions a hospital should take if any of the 29 never events should occur. Some of the nine actions are to waive all costs related to the event; report the error to an external agency; and interview the patient and family to gather evidence for a root cause analysis.

The never-event policy was developed by the Leapfrog Group with feedback from patient-safety experts and reviews of the literature. The decision was made to update the never-event policy two years ago after the Agency for Healthcare Research and Quality developed a toolkit for providers to respond to patient harm events, Binder said. Some elements of the AHRQ toolkit are now part of the Leapfrog policy, such as having a protocol in place to support caregivers involved in never events.

“It’s devastating to caregivers when they have been part of an error that is so harmful to a patient, so they need to be supported as well,” Binder said.

In order to track hospital compliance with the policy, Leapfrog asks hospitals on its biannual survey if they comply. Leapfrog has an audit process where a subset of hospitals is asked for proof of the policy. There are also hospitals that decline to answer the question in the survey, and they weren’t included in the analysis.

In addition to the policy, the Leapfrog Group tracks some never events through the CMS claims database, and it’s considered in hospitals’ safety grade. The CMS refuses to pay for additional costs as a result of never events, and it doesn’t cover any costs associated with wrong-site surgery.

Hospital compliance with the Leapfrog policy was likely slightly lower in 2018 because it was just updated, Binder said, but compliance had been stuck at around 80% for several years. The problem could be that regulators in some states or accrediting agencies don’t enforce such policies, she added.