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To Err Is Human: Building a Safer Health System (2000)
Institute of Medicine (IOM)

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. "D Characteristics of State Adverse Event Reporting Systems." To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press, 2000.

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mary care clinics, psychology clinics, psychiatric health facilities, adult day health centers, chemical dependency recovery hospitals, and correctional treatment centers.

Number of reports

4,337 (1998)

Year initiated

1972 (approximately)

Mandatory or voluntary

Mandatory; must be submitted within 24 hours of the incident.

Access to information

Reports that do not contain confidential information are accessible to the public. Reports that do contain confidential information can be obtained only by subpoena. The local licensing and certification office handles all requests for copies of reports.

Use of information

The state reviews the reported event and determines if an onsite visit is warranted. If violations of the regulations are suspected an onsite visit is conducted. If deficiencies are noted the facility must submit an acceptable plan of correction. Violation of regulations can also result in state or federal citations. Civil penalties of up to $50 per day or enforcement actions can be imposed.

Colorado

Reportable event

All deaths arising from unexplained causes or under suspicious circumstances. Brain and spinal cord injuries. Life-threatening complications of anesthesia. Life-threatening transfusion errors or reactions. Burns; missing persons; physical, sexual, and verbal abuse; neglect, misappropriation of property; diverted drugs; malfunction or misuse of equipment.

Who submits reports

All state-licensed health care facilities.

Number of reports

1,233 (1998)

Year initiated

1989

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