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New Report From The Leapfrog Group Examines Hospital Policies On Never Events

Our partner, The Leapfrog Group, a national watchdog organization of employers and other purchasers focused on healthcare safety and quality, today released its 2019 Never Events Report, and found that one in four participating hospitals do not meet The Leapfrog Group’s standard for handling of serious reportable events that should never happen to a patient, known as “Never Events.” The report is based on the findings from the 2018 Leapfrog Hospital Survey, with data voluntarily submitted by more than 2,000 U.S. hospitals.

The report calls attention to official hospital policies for responding to the 29 serious reportable events as identified by The National Quality Forum (NQF). These include errors and accidents that hospitals should always prevent, such as surgery on the wrong body part, foreign objects left in the body after surgery, death from a medication error, and others that stakeholder consensus has defined as always preventable. The Leapfrog standard for hospital policies includes such steps as: an apology to the patient, not charging for the event, a root cause analysis that includes interviews with patients and family, reporting to appropriate officials, implementing a protocol to care for the caregivers involved and making the policy available to patients and payors.

“When a terrible error occurs, Leapfrog and its constituency of employers and other purchasers expect hospitals to respond with the highest levels of respect and compassion for patients and their families, beginning with a simple apology. Then, hospitals should rely on the sound business principles that all other industries routinely apply when a serious and harmful error occurs, like not charging for the problem and doing a root cause analysis to prevent future reoccurrences. That’s what the Leapfrog Never Events Policy is all about,” said Leah Binder, president and CEO of The Leapfrog Group.

“Patients and payors alike expect that 100% of hospitals will adhere to these basic principles, but unfortunately, we are not seeing that yet, with only 75% of reporting hospitals meeting Leapfrog’s standard.”

Leapfrog’s Never Events Policy includes nine basic principles for response if a Never Event does occur, which is expanded from five principles first issued in 2007. In 2017, The Leapfrog Group’s expert panel recommended adding four new principles as a result of new evidence and testing of best practices by leading health systems, as well as work by national organizations including the Agency for Healthcare Research and Quality and the National Patient Safety Foundation.

The report also found a distinction between how rural and urban hospitals adopt the Never Events Policy. More hospitals in urban areas (77%) are meeting Leapfrog’s new standard compared to hospitals in rural areas (64%).

Consumers and purchasers can and should use Leapfrog’s publicly reported Survey results, available for free at, to determine which hospitals in their community have a Never Events Policy that fully meets Leapfrog’s standard, and which hospitals declined to disclose the information.

About The Leapfrog Group

Founded in 2000 by large employers and other purchasers, The Leapfrog Group is a national nonprofit organization driving a movement for giant leaps forward in the quality and safety of American health care. The flagship Leapfrog Hospital Survey collects and transparently reports hospital performance, empowering purchasers to find the highest-value care and giving consumers the lifesaving information, they need to make informed decisions. The Leapfrog Hospital Safety Grade, Leapfrog’s other main initiative, assigns letter grades to hospitals based on their record of patient safety, helping consumers protect themselves and their families from errors, injuries, accidents and infections.

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