Will we ever get to never? Marking the Fifth Anniversary of Leapfrog's Never Events Policy with our Annual Meeting on December 6th, 2011.
Six thousand never events happen to Medicare beneficiaries every month in the United States, according to estimates in 2010 by the Office of the Inspector General. Never events are the most egregious of safety and quality breakdowns, like removal of the wrong limb in surgery.
Never events provoke more outrage and debate among employer purchasers than any other issue Leapfrog has ever addressed—and we are not known for timidity. That is why exactly five years ago, Leapfrog employer members issued our Never Events Policy, the first national policy stating, among other things, that purchasers expect an apology to the patient and refuse to pay for the costs associated with these tragic errors. Today 60% of Leapfrog reporting hospitals have embraced the policy, most national plans have adopted at least part of it, and hundreds of purchasers have endorsed it. Still, we have a long way to go to better protect Americans.
Will we ever get to never? To help members understand where we are in the patient safety movement, and more importantly, how we get to results in the next five years, we are devoting our member Annual Meeting to three very powerful keynote speakers who bring different—and very disruptive—perspectives. Their remarks are meant to generate member discussion and motivate action.
Dr. Lucian Leape: Will We Ever Get To Never?
Lucian Leape, M.D., is the founding father of the academic discipline studying patient safety. Dr. Leape's international recognition began with publication of his seminal article, Error in Medicine, in 1994. His subsequent research demonstrated the success of the application of systems theory to the prevention of adverse drug events. In addition, he has directed research into overuse and underuse of cardiovascular procedures. He has talked and written widely about the need to make patient safety a national priority, including testifying before Congress and serving on numerous public and private organizational boards and committees. Dr. Leape was a member of the Institute of Medicine's Quality of Care in America Committee, which published "To Err is Human" in 1999 and "Crossing the Quality Chasm" in 2001. Dr. Leape was one of the original leaders of The Leapfrog Group, and remains one of our most steadfast supporters. His keynote speech will share his perspective as the pioneer of the patient safety movement, and will help chart our Never Events path for the future.
Susan Sheridan: When Will Healthcare Put Patients First?
Susan E. Sheridan first became involved in patient safety after her family experienced two serious medical system failures. Her husband, Pat, died in 2002 after his diagnosis of spinal cancer failed to be communicated. Prior to that, their son Cal, suffered brain damage known as kernicterus five days after his birth in 1995 when his neonatal jaundice was untreated. As a result of these experiences, Susan has devoted her career to patient safety efforts. She is Co-Founder and Past President of Parents of Infants and Children with Kernicterus. In 2003, she co-founded Consumers Advancing Patient Safety, a nonprofit organization that seeks a safe, compassionate and just healthcare system through proactive partnership between consumers and providers of care, and later served as its president. In 2004, Susan was asked to lead the World Health Organization's Patients for Patient Safety initiative, a program under the WHO Patient Safety Program. Susan has been named to Modern Healthcare's list of Top 25 Women in Healthcare as well as Modern Healthcare's 100 Most Powerful People in Healthcare. Susan's keynote on Never Events: The Patient Experience will give us a fresh perspective on the reality of when the worst possible medical outcome happens to you.
John Nance: Will Hospitals Learn to Fly?
John J. Nance, JD, is an internationally recognized broadcast analyst for ABC News and leading expert in aviation safety. He is one of the pioneers of the pivotal aviation safety revolution known as CRM (crew resource management). His book, Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care, applies the principles of aviation safety to hospital and health care safety and finds healthcare lagging behind. One of the leading thinkers on matters of major change to America's healthcare system, John's keynote will illustrate what hospitals must do to catch up with the aviation industry and protect the lives of everyone at risk in our healthcare system today.