Never Events Management

How did Leapfrog elevate Never Events to a national priority?

A Never Event is a medical error that should never happen, such as an object left inside a patient or the transfer of a wrong type of blood. Leapfrog utilizes the National Quality Forum's list of serious reportable events in asking hospitals to adopt a Never Events policy. 

Leapfrog's Never Events policy asks hospital to commit to four basic acts if a Never Event does occur: 

  1. apologize to the patient and family, 
  2. waive all costs related to the event and follow-up care,
  3. report the event to an external agency,
  4. conduct a root-cause analysis of how and why the event occurred. 

The hospital must also make a copy of this policy available to patients. All hospitals should abide by these basic pillars of respect in treating those affected by a Never Event. It is publicly reported as Never Events Management on Leapfrog's Hospital Ratings Results page.

Fact sheet on Never Events evidence, measure and standards


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