Yesterday we covered the list of never-events in medicine. Today we cover what our parents should have taught us before we were five-years-old; which is why after a mistake you offer a sincere apology. Whoever they are, the Leapfrog Group advises doctors and hospitals about what to do when the S-H-T-F and the surgical team operates on the wrong-patient, does the wrong procedure or cuts the patient on the wrong body part. Follow my lead and read what they publish about these grossly negligent errors.

The Leapfrog Group offers four actions as industry standards following a never event:[3]

1. apologize to the patient
2. report the event
3. perform a root cause analysis
4. waive costs directly related to the event

^ "Half of US hospitals reporting to Leapfrog say they won't bill for a “never event”". The Leapfrog Group. September 26, 2007. http://www.leapfroggroup.org/media/file/Release_-_Adoption_of_Leapfrog_Never_Events_Policy_2007.pdf. Retrieved October 19, 2010. 

^ "Serious Reportable Events (SREs): Transparency & Accountability are Critical to Reducing Medical Errors". National Quality Forum. October 1, 2008. http://www.qualityforum.org/pdf/news/prSeriousReportableevents10-15-06.pdf. Retrieved October 19, 2010. 

^ "Factsheet Never Events". The Leapfrog Group. March 27, 2008. http://www.leapfroggroup.org/media/file/Leapfrog-Never_Events_Fact_Sheet.pdf. Retrieved October 19, 2010.

Leapfrog says it's their belief a sincere apology is in everyone's best interest. Yeah I’d have to agree. But why do you have to tell grownups to apologize after they operated on the wrong patient? You mean the surgical staff doesn't just apologize? What's wrong with this picture?

Here is what that group says: "It is Leapfrog’s belief that it is within the best interest of all parties involved for the hospital staff to give a verbal apology and explanation of the known circumstances surrounding the never event to the patient and/or family affected. Research indicates that patients who are victims of adverse events feel the most anger when they perceive that no one is willing to take responsibility for what has happened. A sincere apology from the responsible hospital staff can help to heal the breach of trust between doctor/hospital and patient and may reduce the hospital’s risk of liability. (When Things Go Wrong: Responding to Adverse Events. Mass Coalition for the Prevention of Medical Errors. Boston, 2006)"

Oh come on, please stop you're making me laugh. You mean you had to do research to know a patient who just had the wrong side of their skull removed might be angry? Really, I would have never guessed. Your group has to tell grownups that a sincere apology is necessary? Is this a joke? If you have to tell a grownup to apologize it will never be sincere. Give me a break.

Leapfrog then goes on to say: "According to the National Quality Forum, “the primary reason for identifying a standardized set of serious reportable events that would be mandatorily reported is to facilitate public accountability for the occurrence of these adverse events in the delivery of
healthcare.” (Serious Reportable Events in Healthcare: A Consensus Report. NQF. 2002) Since the U.S. health care system does not currently have one national reporting program in place, the
Leapfrog Group asks hospitals to choose at least 1 of 3 reporting options: the Joint Commission, a state reporting program, or a Patient Safety Organization. It asks that the hospital reports to its chosen entity within 10 days of its self determination that a never event has occurred."

Never events are for all practical purposes on the same par as quasi-criminal behavior. They are grossly negligent events that sloppy surgical teams make and ignorant ones refuse to acknowledge setting the stage for further errors that destroy lives. If the legal system has to tell a criminal to apologize to its victim then they deserve incarceration, not the loot they just stole.

Someone call a lawyer, I may have just had an aneurysm.

To read more about the Apology Shield follow this link to posts by Steve Lombardi.