To Err Is Human Building a Safer Health System (2000) / Chapter Skim
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Appendix D: Characteristics of State Adverse Event Reporting Systems
Appendix D: Characteristics of State Adverse Event Reporting Systems
Pages 254-265
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General acute care hospitals, acute psychiatric hospitals, skilled nursing facilities, immedi ate care facilities, home health agencies, pri Who submits reports 254
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Burns; missing persons; physical, sexual, and verbal abuse; neglect, misappropriation of property; diverted clrugs; malfunction or misuse of equipment. All state-licensecl health care facilities.
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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.
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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)
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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.
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All licensed health care facilities. Not provided 1993 Mandatory Actual reports are not accessible to the public; however statements of deficiencies and plans of correction are available by request.
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The health department can impose fines, curtail admissions, appo~nt a temporary manager, issue a prov~sional license, suspend a facility's license, or close the facility. An unintended adverse and undesirable development in an individual patient's condition occurring in a hospital.
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The state also intends to develop regional error rates for benchmarking and dissemination to regional councils that are being formed. Death or injury resulting from equipment malfunction or treatment of the wrong subject or wrong modality.
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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. Hospitals, nursing homes, home health agencies, ambulatory surgical facilities, intermediate care facilities for persons with developmental disabilities.
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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
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All licensed health care facilities. The health department has not kept track of the exact number of reports received.
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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.
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