The importance of never
In dealing with never events, focus on harm to patients, not the blame game
When Captain Chesley “Sully” Sullenberger safely landed US Airways Flight 1549 in the Hudson River a little over a year ago, recession-weary Americans rejoiced at this small sign that American courage and know-how could still save the day. After a fluke collision with birds shortly after takeoff disabled both engines, Sullenberger and crew coolly glided the jet to a landing on the river, and safely evacuated all of the passengers. Though this was surely one of the great moments in airline history, it was also a “never event” — a catastrophe that we hope never happens and expect airlines to prevent at all costs.
The healthcare system’s “never events” are incidents so awful most people cannot hear about them without wincing: removal of the wrong limb in surgery, transfusion of the wrong blood type, sexual assaults on patients, discharge of infants to the wrong parent, and more, for a total of 28 horrific events identified by the National Quality Forum as “serious reportable events (SREs) that should never happen.” The existence of this ghoulish list tells us that these incidents, unfortunately, do occur sometimes—just as a plane landed in the Hudson. Nonetheless, as a goal, “never” seems a reasonable aspiration for the frequency of these catastrophes.
In 2006, the Leapfrog Group, representing the nation’s largest purchasers of healthcare benefits, unveiled principles for hospitals focused on the NQF’s list of 28 events, and in doing so coined the term “never events.” Leapfrog’s never events principles drew on purchasers’ experience with customer service norms in their various industries, from airlines to automakers to hospitality. Leapfrog asks hospitals to adhere to four simple principles. In 2009, 68% of hospitals reporting to Leapfrog adopted these four principles. Encouraging as this may be, still one-third of those hospitals do not have the policy in place.
Why do some hospitals object to adopting a never-events policy? Some tell us they worry about lawsuits if they apologize to the patient, even though studies show apologies vastly reduce the odds of lawsuits. Others are concerned that some events are flukes that may not have been preventable, so why should hospitals have to bear the cost? This concern about preventability in each and every circumstance fuels a controversy at the National
US Air’s response matched Leapfrog’s principles even though the crash
Quality Forum today as the membership revisits the definition of SREs. Unfortunately, the debate at the NQF pivots around how preventable the incident is, not on how catastrophic it would be for the patient.
Purchasers tend to think it’s worth erring on the side of calling every egregious incident a “never event,” even if on occasion it wasn’t preventable. To understand that perspective, let’s reflect on our friend “Sully.” We know the crash wasn’t his fault and wasn’t preventable, yet the airline’s response matched Leapfrog’s four principles to the letter.
Apologize: The day after the crash, US Airways sent a letter to every passenger apologizing for the event. At the time, investigators were still in the process of determining what was responsible for the crash, but US Airways did not wait for those conclusions to extend its apology. Airlines have to worry about lawsuits, too, but the simple humanity of the apology was too important to sacrifice. This also likely reduced, if not eliminated, the number of subsequently filed lawsuits.
Report the event: Investigators were immediately on the scene, and reports are made public and shared with all airlines.
Do a root-cause analysis: Not only does the airline do a root-cause analysis for its own use, but as per industry standard, it shares those results with all airlines.
Waive fees: Along with the letter of apology, US Airways refunded each passenger the cost of their round-trip ticket plus $5,000 for their troubles. This was not required by law.
The airline waived fares and apologized despite the fact that all early evidence—later substantiated—suggested this crash was not the fault of the airline or the pilot. To the contrary, the pilot and crew performed with exceptional competence and even heroism.
Now imagine public dismay if the airline had not waived the fare for the ticket and worse, billed passengers for the cost of the rescue operations. Sadly, that’s not unthinkable in the healthcare system, where providers have charged the patient for the costs of a catastrophic incident, then charged them for repairing the damage.
Purchasers care about Leapfrog’s position on never events because it embodies the standards for customer service that other industries adhere to, especially industries that enjoy exceptional levels of public trust. Given that people entrust their lives to the healthcare system, it seems a small price to pay that providers bear the brunt of responsibility for averting the most devastating errors.
At the time “Sully” landed the plane safely, the public had no way of knowing for sure who or what was to blame for the crash. What impressed people were the extraordinary efforts of the captain, the crew and the airline to put the passengers first. A never-events policy is a reassuring way for healthcare providers to demonstrate they put patients first.
By setting the bar at “never,” providers acknowledge the terrible consequences patients stand to suffer if the worst happens in our fallible healthcare system. That’s why purchasers will continue to press for hospitals, health plans and NQF membership to take the strongest possible stance on never events.
Leah Binder is CEO of the Leapfrog Group, a group of large
purchasers of healthcare services that pushes for quality