One in 5 hospitals failed to meet the standard for “never events” management, according to a report from The Leapfrog Group, a nonprofit pushing for quality and safety in American health care.

“Never events” are egregious hospital errors such as wrong-site surgery, wrong-patient surgery, objects left in patients after surgery, and deaths from medication errors or falls. According to Leapfrog, 29 types of serious reportable events have been identified as “never events” by the National Quality Forum.

Leapfrog began surveying hospitals starting in 2007 to determine whether they had implemented best practices to avoid and manage “never events.” The group came up with a 5-step plan to implement after a “never event” happens: 1) apologize to the patient and family; 2) report the event to an outside agency within 10 days of becoming aware of it; 3) perform a root-cause analysis to identify the cause of the error; 4) waive costs directly related to the “never event” so that neither the patient nor the payer is billed; and 5) make the policy available to patients, patients’ family members, and payers.

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In 2007, only 53% of hospitals had a “never events” policy that met these criteria. By 2012, that percentage had increased to 79% and has held steady between 79% and 80% in the past 4 annual surveys. Leapfrog concludes that despite 80% of hospitals surveyed having a policy, improvement is still needed. “While any given patient has a low probability of experiencing one of these events, the patients who do experience these errors can often face severe and irreversible consequences,” stated the report.


  1. Lagasse J. Leapfrog: Many hospitals still fail in preventing ‘never event’ medical errors. Healthcare Finance. June 10, 2016. Accessed June 20, 2016.