Window to Washington

An inside-the-beltway look at the legislative and regulatory process.

Leapfrog chief pushes ‘never events’ policy

By Jessica Zigmond

Why? Why not?! That’s what hospital executives and workers should ask their board members if their facilities don’t have a “never events” policy in place to prevent medical errors.

Leah Binder, CEO of the Leapfrog Group, tasked attendees with that challenge during the patient safety organization’s annual meeting Tuesday at the Hyatt Regency in Crystal City, Va. This year, Leapfrog honored 65 hospitals with the organization’s “Top Hospital” designation. That award recognizes hospitals that deliver the highest quality care by preventing medical errors, reducing mortality for at-risk procedures and reducing hospital readmissions for patients.

I asked Binder—who said in her remarks that not all hospitals have a “never events” policy in place—what she thinks is holding health systems back from implementing such a strategy.

“They’re afraid of liability and they listen to too many lawyers who tell them to be afraid of liability,” Binder said. “I tell them not to be afraid of their own patients and to get new lawyers,” she added. “Hospitals that apologize to the patient are far less likely to face litigation.”

Meanwhile, attendees at this year’s meeting praised the various keynote speakers and were left with the message that strong communication and team approaches are essential to improving patient safety.

“I think what was different about the message this time around was: it was around communication,” said Dolores Gomez, COO at Mills-Peninsula Health Services (an affiliate of Sutter Health) in Burlingame, Calif. “It was around teams. It was around the fact that it really is around relationships in terms of how medical errors can be avoided and how crucial that is in terms of patient safety. And that’s been a real interesting message this year.”

Gomez also reflected on comments from one of the keynote speakers, Dr. Lucian Leape, the Harvard physician who heads the Lucian Leape Institute at the National Patient Safety Foundation.

“It has to be a team; it can no longer be the physician as a leader and omnipotent,” Gomez said of Leape’s comments. “It really needs to be the whole team that’s working together to ensure that the best care in the safest way can be provided to the patients, and I think that itself is the key message today.”


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