National Academies Press: OpenBook

To Err Is Human: Building a Safer Health System (2000)

Chapter: D Characteristics of State Adverse Event Reporting Systems

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Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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D—
Characteristics of State Adverse Event Reporting Systems

California

Reportable event

Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes, or other catastrophes and unusual occurrences that threaten the welfare, safety, or health of patients, personnel, or visitors. Other occurrences include, but are not limited to, prevalence of communicable disease; infestation by parasites or vectors; disappearance or loss of a patient or inmate-patient; sexual acts involving patients who are minors; nonconsenting adults, or persons incapable of consent; physical assaults on inmate-patients, employees, or visitors; and all suspected criminal activity involving inmate-patients, employees, or visitors.

Who submits reports

General acute care hospitals, acute psychiatric hospitals, skilled nursing facilities, immediate care facilities, home health agencies, pri-

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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Page 256

Mandatory or voluntary

Mandatory under Colorado State Statute 25-1-124(2).

Access to information

The name of the facility is disclosed. Patient and personnel information is kept confidential. Report summaries are posted on the Internet once the facility investigation is complete.

Use of information

An advisory committee meets monthly to identify patterns and issues. Summaries of the reviewed reports are sent out to the facilities and they have seven days to comment. The state will issue deficiencies if deemed necessary. All information is entered into a computer program for tracking. Surveyors and investigators review the information in the institution-specific database prior to conducting the regular survey and complaint investigations.

Connecticut

Reportable event

All accidents or incidents that resulted in serious injury, death, or disruption of facility services.

Who submits reports

Nursing homes and hospitals.

Number of reports

14,783 (1996)—approximately 14,000 from nursing homes.

Year initiated

1987

Mandatory or voluntary

Mandatory for nursing homes; voluntary for hospitals.

Access to information

Reports disclose the name of the facility, but no information on patients or personnel. To obtain a report, one must fill out a Freedom of Information Act form and submit the request to the health department.

Use of information

Information is reviewed by a nurse consultant who determines if there needs to be an investigation by the health department.

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 257

Florida

Reportable event

Urgent issue: life-threatening situation, epidemic outbreak. Code 15: serious adverse event (i.e., wrongful death, brain injury, wrong limb removal, incorrect surgery).

Who submits reports

Hospitals and ambulatory surgical centers.

Number of reports

Approximately 5,000 a year; 4,000 are urgent issue and 1,000 are Code 15.

Year initiated

1985

Mandatory or voluntary

Mandatory

Access to information

A summary of the aggregate data collected from reports is issued once a year. All other information is confidential and cannot be released without a subpoena.

Use of information

Urgent-issue situations are considered to be outside the facility's control; and thus no facility follow-up is required. When reporting a Code 15, an analysis of the injury and a plan of correction must be submitted by the facility within 15 days. The state's risk management program tracks trends in the reporting.

Kansas

Reportable event

An act by a health care provider that (1) is or may be below the applicable standard of care and has a reasonable probability of causing injury to a patient or (2) may be grounds for disciplinary action by the appropriate licensing agency.

Who submits reports

All licensed medical care facilities.

Number of reports

488 (1997)

Year initiated

1986

Mandatory or voluntary

Mandatory

Access to information

All reports are confidential. All peer review information and standard of care determinations are protected under the risk management statutes. Only the facts of the case

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 258

 

have been subpoenaed. The name of the reporter is protected.

Use of information

Each facility must establish a written plan for risk management and patient care quality assessment on a facility-wide basis. This initial plan must be submitted to the health department at least 60 days prior to the licensure date. The plan will be reviewed and the facility will be notified in writing concerning plan approval. The facility's governing board must review and approve the risk management plan on an annual basis. All changes must be approved by the department. Following an incident, the department will review the facility's plan to ensure that it is adequate. Depending on the severity of the incident, the department will then possibly conduct an investigation.

Massachusetts

Reportable event

Injury that is life-threatening, results in death, or requires a patient to undergo significant additional diagnostic or treatment measures. Medication errors. Major biomedical device or other equipment failure resulting in serious injury or having potential for serious injury. Surgical errors involving the wrong patient, the wrong side of the body, the wrong organ, or the retention of a foreign object. Blood transfusion errors. Any maternal death within 90 days of delivery or termination of a pregnancy. Death of a patient by suicide.

Who submits reports

All licensed health care facilities.

Number of reports

10,500 (1997); 390 were from hospitals

Year initiated

1986

Mandatory or voluntary

Mandatory

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 259

Access to information

Copies of reports submitted by facilities are available to the public after official action has been taken by the health department. The identity of the patient is removed. Reports relating to abuse, neglect, or misappropriation are confidential and are not released.

Use of information

All reports are entered into a Massachusetts Health Department database and are reviewed. This database is used to retain information on the individual case and look for general patterns across cases. Depending on the incident, the department can decide to contact the facility for more information or conduct a site visit. Deficiencies are cited if the facility is found to have not reported all relevant information.

Mississippi

Reportable event

Suicide or attempted suicide, wrongful death, unexplained injuries, abuse, and interruptions of service at the facility.

Who submits reports

All licensed health care facilities.

Number of reports

Not provided

Year initiated

1993

Mandatory or voluntary

Mandatory

Access to information

Actual reports are not accessible to the public; however statements of deficiencies and plans of correction are available by request. The health department does spend a great deal of time in litigation with malpractice attorneys who are attempting to subpoena its records.

Use of information

Attempts are made to identify trends in the data received, and the department's findings are discussed with the facility.

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 260

New Jersey

Reportable event

Any incident that endangers the health and safety of a patient or employee and any death or injury associated with anesthetics.

Who submits reports

All state licensed health certificates.

Number of reports

Not provided

Year initiated

1986

Mandatory or voluntary

Mandatory

Access to information

Information is disclosed only in the event that the facility receives a citation from the state. Penalty letters revealing the name of the facility and describing the incident that led to the citation are posted on the Internet. Patient and personnel information is kept confidential.

Use of information

If deemed necessary, a state inspection team is sent to investigate the facility. The team's findings are shared with the facility, which must comply with the report's recommendations or be cited with deficiencies. Then the facility must submit a plan of correction for each deficiency. The health department can impose fines, curtail admissions, appoint a temporary manager, issue a provisional license, suspend a facility's license, or close the facility.

New York

Reportable event

An unintended adverse and undesirable development in an individual patient's condition occurring in a hospital. A list of 47 occurrences is included on a specification of reportable events.

Who submits reports

Hospitals

Number of reports

15,000–20,000 reports each year

Year initiated

1986

Mandatory or voluntary

Mandatory

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 261

Access to information

Narrative reports on incidents and the investigations conducted are protected by law, but the state can release aggregate data by hospital, including the number of reports submitted. State actions against a facility are posted on the Internet (whether the source was the reporting system, patient complaint, or other).

Use of information

The state may investigate specific incidents. If the hospital has taken action acceptable to the department, the case is closed. If the violation persists, the state may issue deficiencies or fines. The state also intends to develop regional error rates for benchmarking and dissemination to regional councils that are being formed.

Ohio

Reportable event

Death or injury resulting from equipment malfunction or treatment of the wrong subject or wrong modality.

Who submits reports

Free-standing therapy, imaging, and chemotherapy centers

Number of reports

Not provided

Year initiated

1997

Mandatory or voluntary

Mandatory

Access to information

Governed under Ohio's public record law. This law prohibits the collection of patient-specific information. The state will only be releasing aggregate data on the incidents reported. Facilities will have access only to their own information. The state plans to compile an annual report on incidents that will be available to the public.

Use of information

A database is being developed to track the number of reports received and provide an indicator of which facilities should be inves-

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 262

 

tigated. The goal is to identify noticeable trends in types of errors. The director of health monitors compliance and can inspect any health care provider. Health care providers may be required to regularly issue reports and undergo independent audits.

Pennsylvania

Reportable event

An event that seriously compromises quality assurance or patient safety, including: deaths due to injuries, suicide, or unusual circumstances; deaths due to medication error; deaths due to malnutrition, dehydration, or sepsis; elopements; patient abuse; rape; surgery on the wrong patient or modality; hemolytic transfusion reaction; infant abduction or discharge to wrong family; fire or structural damage; unlicensed practice of a regulated profession.

Who submits reports

Hospitals, nursing homes, home health agencies, ambulatory surgical facilities, intermediate care facilities for persons with developmental disabilities.

Number of reports

Not provided

Year initiated

1990

Mandatory or voluntary

Mandatory

Access to information

All collected information is confidential. Reports are often shared only with another state agency. They are not considered public material and were not intended to provide information to the public. The department usually requests that courts overrule subpoenas, and in the majority of cases its request is granted.

Use of information

On some occasions, the department will request more information from a facility and conduct investigations. This is usually done when there is a recurrence of incidents or

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 263

 

drug misappropriation. Very few cases have resulted in a fine to a facility following an adverse event.

Rhode Island

Reportable event

Any incident causing or involving the following: brain injury; mental impairment; paraplegia; quadriplegia; paralysis; loss of use of limb or organ; birth injury; impairment of sight or hearing; surgery on the wrong patient; subjecting a patient to any procedure that was not ordered or intended by the physician.

Who submits reports

Hospitals

Number of reports

134 (1998) from 15 facilities

Year initiated

1994

Mandatory or voluntary

Mandatory

Access to information

The names of personnel and patients are not disclosed in submitted reports. All reports are confidential and are protected by law. The hospital involved is contacted whenever the health department receives a subpoena from an attorney. The hospital may initiate proceedings to quash the subpoena. However, if the state takes action against the facility—for example, following a site investigation—then this information may be disclosed to the public.

Use of information

Reports are reviewed by department staff and filed. If deemed warranted, an investigation of the incident will be conducted. After submitting a report the hospital must conduct a peer review process to determine whether the incident falls within the normal range of outcomes, given the patient's condition. If the hospital's findings conclude that the in-

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 264

 

cident was outside the normal range, the hospital must provide the health department with the following information: an explanation of the circumstances surrounding the incident; an updated assessment of the effect of the incident on the patient; a summary of current patient status including follow-up care provided and post-incident diagnosis; and a summary of all actions taken to correct the problems identified to prevent recurrence and/or improve overall patient care. Incidents that are determined to have fallen within a normal range of outcomes by the hospital are reviewed by the health department. In the event that the health department disagrees with the hospital's findings, a separate investigation is conducted and peer review documents are examined.

South Dakota

Reportable event

Unnatural deaths; missing patients or residents; incidents of abuse, neglect, or misappropriation.

Who submits reports

All licensed health care facilities.

Number of reports

The health department has not kept track of the exact number of reports received. The majority are submitted by nursing homes.

Year initiated

1994

Mandatory or voluntary

Mandatory

Access to information

Reports are completely confidential, unless a deficient practice is identified at the facility. A summary of the cited deficiency is releasable information. As required by state law, a judicial court order must be issued before the health department will release any other information.

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×

Page 265

Use of information

Each incident report is analyzed to assess whether the facility did everything possible to avert the incident. If it did not, the facility will be cited and then they must develop a plan of correction.

SOURCE: Information for this table was collected from each state health department by telephone between February 24 and May 5, 1999. Each respondent was given the opportunity to review the draft and correct any errors.

Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 254
Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 255
Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 256
Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 257
Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 258
Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 259
Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 260
Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 261
Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 262
Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 263
Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 264
Suggested Citation:"D Characteristics of State Adverse Event Reporting Systems." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
×
Page 265
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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.

To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system.

This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes.

Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errors--which begs the question, "How can we learn from our mistakes?"

Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care.

To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocates--as well as patients themselves.

First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

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