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Adverse Event Reporting Tools by State

California requires the reporting of unusual occurrences which threaten the welfare, safety, or health of patients. Legislation was enacted in 2006 to codify reporting of adverse events, operative as of July 1, 2007.  The legislation requires information about reported events and the outcome of investigations or inspections of substantiated adverse events to be made readily accessible to consumers by January 2009 and posted on the state department of health service's Website and available in written form by January 2015.
All healthcare facilities licensed by the Colorado Department of Public Health and Environment are required to report occurrences to the Health Facilities and Emergency Medical Services Division.
The State of Connecticut Public Act 2202-125 (P.A. 02-125) included a requirement for the Connecticut Department of Public Health to establish a quality of care program for health care facilities.  The law requires the implementation of adverse event reporting by hospitals and outpatient surgical facilities.  Mandatory adverse event reporting was implemented in October 2002.  In May 2004, Public Act 2004-164 (P.A. 04-164) was enacted to revise the definition of reportable adverse events.
In December 2006, the District of Columbia Council passed the Medical Malpractice Amendment Act of 2006, A16-0619, which became effective March 2007. The Act mandates three (3) reporting requirements effective July 1, 2007. The Health Regulation and Licensing Administration is currently in the process of drafting regulations. As of April 2009, interim guidelines are available for the Medical Malpractice Amendment Act of 2006.
The State of Florida, Agency for Health Care Administration, administers serious patient injury reporting, tracking, trending, and problem resolution programs in hospitals and ambulatory surgical centers, as authorized in Chapter 395.0197 F.S. The law also requires that licensed health care risk managers implement programs prescribed by statute to accomplish these processes, which include continuing quality assessment and improvement and assuring greater patient safety in each of these facilities. The main thrust of the programs is identifying incidents occurring in health care facilities, which have an outcome of patient injury and may reflect error in the course of the delivery of health care services. Facilities are required to provide the Agency for Health Care Administration with two separate types of reports: Annual Reports and Code 15 Reports.  Annual Reports outline all of the adverse events subject to mandatory reporting occurring during the previous calendar year.  Code 15 Reports are due within 15 days of a reportable adverse event (though the Agency for Health Care Administration has the authority to grant extensions).  Code 15 Reports require a detailed summary, analysis, and corrective action plan for each incident.
Georgia rules and regulations for hospitals require hospital peer review committees to report to the Georgia Department of Human Resources Office of Regulatory Services whenever a reportable incident involving hospital patients occurs, or when the hospital has reasonable cause to believe that a reportable incident involving a patient has occurred.  Similar reporting requirements have been implemented for laboratories, dialysis facilities, residential child care facilities, residential mental health facilities, and X-ray imaging facilities.
The Illinois Adverse Health Care Events Reporting Law of 2005 establishes an adverse health care event reporting system designed to facilitate quality improvement in the health care system through communication and collaboration between the Illinois Department of Public Health and health care facilities. The reporting system will not be designed or, except as provided in this law, used to punish errors or to investigate or take disciplinary action against health care facilities, health care practitioners, or health care facility employees.  The Department was required to establish a fully operational adverse health event reporting system by January 1, 2008. As of April 30, 2009, implementing regulations were still in the rulemaking process.
Governor Mitch Daniels issued an executive order (#05-10) in January 2005 directing the Indiana Department of Health to promulgate regulation and, if necessary, propose legislation requiring each hospital in the state to implement a medical error reporting and quality system (MERS) and to report all MERS data to the Department of Health.  The system has been operating since January 2006.
The Kansas Legislature enacted legislation in 1986 that requires licensed medical care facilities to establish and implement internal risk management programs, such as incident reporting systems, as a condition of licensure. Facilities are required to report specific information on internal incidents that, based on the determination of the facility’s risk management committee, qualify as Standard of Care III incidents (standard of care did not meet determinations, with injury occurring of reasonably probable) and Standard of Care IV incidents (possible grounds for disciplinary action by the appropriate licensing agency).
Maine has established a system for reporting sentinel events for the purpose of improving the quality of health care and increasing patient safety.  Within one day of the occurrence of a sentinel event, facilities must call at Sentinel Event Hot Line.  Additional analysis and reporting follows the oral report.
The Office of Health Care Quality (OHCQ) of the Maryland Department of Health and Mental Hygiene administers the mandatory reporting system in Maryland.  Maryland hospitals are now required to have policies facilitating the internal reporting of “near misses” in addition to adverse events, and root cause analyses must be performed on all near misses and adverse events.   Facilities are also required to craft and implement plans to prevent these serious problems from recurring. To help prevent adverse events, OHCQ collaborates with the Maryland Patient Safety Center, an AHRQ-recognized patient safety organization.
The Massachusetts Department of Public Health administers a mandatory reporting system for the reporting of incidents that seriously affect the health and safety of patients in hospitals. Note:  Massachusetts administers two mandatory reporting systems.  This toolbox features the system administered by the Massachusetts Department of Public Health.  The alerts and advisories, however, are issued by the system administered by the Board of Registration in Medicine's Patient Care Assessment Program.
The Adverse Health Events Reporting Law, passed during the 2003 legislative session and modified in 2004, provides health care consumers with information on how well hospitals and outpatient surgical centers are doing at preventing adverse events. The law requires that hospitals disclose when any of 28 “never events” occur and requires the Minnesota Department of Health to publish annual reports of the events by facility, along with an analysis of the events, the corrections implemented by facilities, and any recommendations for improvement in Minnesota.
In 2004, the New Jersey Patient Safety Act (P.L. 2004, c9) was signed into law. The statute was designed to improve patient safety in hospitals and other health care facilities by establishing a medical error reporting system.  Events must be reported to the New Jersey Department of Health and Senior Services.  The system promotes comprehensive reporting of adverse patient events, systematic analysis of their causes, and creation of solutions that will improve health care quality and save lives.

The Nevada State Health Division is responsible for maintaining the Sentinel Events Registry through its Bureau of Health Planning and Statistics.  Assembly Bill 1 (AB1) was passed during the 2002 18th Special Legislative Session, and mandatory reporting of sentinel events was incorporated into Nevada Revised Statute (NRS) 439.800-890 and Nevada Administrative Code (NAC) 439.900-920.

In keeping with the goal of providing quality, safe health care, the New York Department of Health developed the New York Patient Occurrence Reporting and Tracking System (NYPORTS).  For the purpose of NYPORTS reporting, an occurrence is an unintended, adverse, and undesirable development in an individual patient's condition.  The data that is collected in NYPORTS is available to facilities to assist them in internal quality initiatives and medical error prevention.
Ohio previously had quality-of-care reporting requirements for nine types of care commonly provided in hospitals.  Those rules have since been rescinded.  Currently, Ohio requires hospitals to report the frequency with which certain commonly accepted best practices (e.g. administration of aspirin following a heart attack) are adhered to, as well as the frequency of various adverse events (e.g. respiratory failure following surgery).  Reports are to be filed on a semi-annual basis. According to this presentation, Ohio is in the process of implementing new adverse event reporting legislation. The Ohio Department of Health, Division of Quality Assurance hopes to begin mandatory reporting in fall 2009.  A website for consumers will be operational in early 2010.
Legislation authorizing the Oregon Patient Safety Commission was enacted in 2003. The Oregon Patient Safety Commission is a semi-independent state agency charged by the Oregon Legislature with reducing the risk of serious adverse events occurring in Oregon's health care system and encouraging a culture of patient safety. The Commission operates a confidential, voluntary, adverse event reporting program in Oregon. The Commission provides an independent voice for patient safety in the state of Oregon through adverse event reporting, evidence-based prevention practices, and quality improvement.  
The Patient Safety Authority is an independent state agency established under Act 13 of 2002, the Medical Care Availability and Reduction of Error ("MCARE") Act.  It is charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety in hospitals, ambulatory surgical facilities and birthing centers.  The Authority has implemented PA-PSRS, the mandatory statewide Pennsylvania Patient Safety Reporting System.  More than 400 healthcare facilities subject to Act 13 reporting requirements are submitting reports through PA-PSRS, making Pennsylvania the first state in the nation to require the reporting of both actual events and "near misses."
Rhode Island Statutes, Section 23-17-40, requires reporting of reportable events to the Rhode Island Department of Health Division of Facilities Regulation.  The department is required to issue an annual report by March 31 of each year providing aggregate summary information on the events and incidents reported by hospitals.
South Carolina regulation mandates incident and accident reporting to the South Carolina Department of Health and Environmental Control as part of the state’s quality oversight of licensed facilities.
According to administrative rule (Administrative Rules of South Dakota 44:04:01:07), South Dakota facilities are required to report deaths resulting from other than natural causes originating on facility property, such as accidents, abuse, negligence, or suicide.
The Health Data Reporting Act of 2002 #68-11-211 requires the reporting of unusual events to the Tennessee Department of Health.  The purpose of the reporting system is to facilitate the development and implementation of best standards practices among health care providers.  The state hopes that the early detection of medical errors and unexpected events, as well as the identification of measures to improve the delivery of health care and to prevent the recurrence of such errors, will enhance the quality of health services delivered to Tennesseans.
The State of Utah initiated its patient safety program through the use of two administrative rules.  R380-200, entitled the Patient Safety Sentinel Event Report, requires all licensed hospitals and ambulatory surgical centers to report the occurrence of sentinel events and the findings and action plans of the root cause analyses that follow.  R380-210, entitled the Health Care Facility Patient Safety Program, requires all licensed hospitals and ambulatory surgical centers to report on an annual basis through the UB92 HCFA administrative billing structure ICD9 coded adverse drug events.  Additionally this rule requires a once every three year independent audit of each facility's adverse drug event reduction program.  Both of these administrative rules are authorized under Title 26-1-30(a), (b), (d), (e), and (g) and Section 26-3-8.
In 2006 , Vermont required the commissioner of health to establish a comprehensive patient safety surveillance and improvement system for the purpose of improving patient safety, eliminating adverse events in Vermont hospitals, and supporting and facilitating quality improvement efforts by hospitals.
The Washington State Department of Health instituted a reporting requirement for adverse events in 1999. Legislation was enacted in 2006 to codify reporting of adverse events.  The legislation requires the establishment of an adverse health event and incident reporting system designed to facilitate quality improvement in the health care system, improve patient safety, and decrease medical errors in a nonpunitive manner.  The department of health is required to contract with a qualified independent entity to carry out the activities specified.
The Wyoming State Legislature passed a bill (Senate File 0113) during the 2005 session requiring all licensed healthcare facilities in the state to report any occurrence of a defined set of patient safety events.  The purpose of this law is to provide the Wyoming Department of Health (WDH) with information that can be used to identify trends in healthcare facility safety events.  This information can then be used to assist healthcare facilities in reducing the severity and incidence of safety events. At the end of each year, the WDH will prepare an aggregate report, without facility or facility employee names, on medical safety events in the state, and will make any necessary recommendations to reduce such events.
In 2009, New Hampshire enacted legislation to require the reporting of 28 listed adverse events in hospitals and ambulatory surgical centers.  Beginning January 1, 2010, hospitals and surgical centers will be required to report to the Commissioner of the Department of Health and Human Services (DHHS) when any of the 28 adverse events occur.  Deidentified reports must be made within 15 working days of the discovery of such an event.  The legislation requires DHHS to establish a non-punitive system of reporting that will include the mandatory completion of root cause analyses and corrective action plans.  The Commissioner will also be required to publish an annual report summarizing the adverse events of the past year, and he or she will be charged with recommending updates to the initial list of 28 events to the legislature.
Advisory groups
Authorizing statutes or regulations
Public reports
Reportable event forms
Reportable event forms
Reportable event forms
Reportable event forms
Reportable event forms
Reportable event forms
State websites
User's guide for facilities
User's guide for facilities
User's guide for facilities
User's guide for facilities
Illinois
Advisory groups Illinois
Authorizing statutes or regulations Illinois
Authorizing statutes or regulations Illinois
State website Illinois
Massachusetts
Advisory groups Massachusetts
Alerts and advisories Massachusetts
Alerts and advisories Massachusetts
Authorizing statutes or regulations Massachusetts
Authorizing statutes or regulations Massachusetts
Authorizing statutes or regulations Massachusetts
Lists or clarifications of reportable events Massachusetts
Lists or clarifications of reportable events Massachusetts
Public reports Massachusetts
Public reports Massachusetts
Reportable event forms Massachusetts
State website Massachusetts
User's guide for facilities Massachusetts
User's guide for facilities Massachusetts
User's guide for facilities Massachusetts
Pennsylvania
Advisory groups Pennsylvania
Alerts and advisories Pennsylvania
Alerts and advisories Pennsylvania
Authorizing statutes or regulations Pennsylvania
Lists or clarifications of reportable events Pennsylvania
Public reports Pennsylvania
Public reports Pennsylvania
Reportable event forms Pennsylvania
Reportable event forms Pennsylvania
State website Pennsylvania
Georgia
Alerts and advisories Georgia
Authorizing statutes or regulations Georgia
Lists or clarifications of reportable events Georgia
Lists or clarifications of reportable events Georgia
Reportable event forms Georgia
Reportable event forms Georgia
State website Georgia
User's guide for facilities Georgia
User's guide for facilities Georgia
Maryland
Alerts and advisories Maryland
Authorizing statutes or regulations Maryland
Lists or clarifications of reportable events Maryland
Public reports Maryland
Public reports Maryland
Reportable event forms Maryland
Reportable event forms Maryland
State website Maryland
User's guide for facilities Maryland
Minnesota
Alerts and advisories Minnesota
Alerts and advisories Minnesota
Alerts and advisories Minnesota
Alerts and advisories Minnesota
Authorizing statutes or regulations Minnesota
Lists or clarifications of reportable events Minnesota
Lists or clarifications of reportable events Minnesota
Minnesota Adverse Health Events Measurement Guide Minnesota
Public reports Minnesota
Public reports Minnesota
Public reports Minnesota
Public reports Minnesota
Public reports Minnesota
Public reports Minnesota
State website Minnesota
Nevada
Alerts and advisories Nevada
Authorizing statutes or regulations Nevada
Authorizing statutes or regulations Nevada
Lists or clarifications of reportable events Nevada
Reportable event forms Nevada
State websites Nevada
User's guide for facilities Nevada
Oregon
Alerts and advisories Oregon
Authorizing statutes or regulations Oregon
Public reports Oregon
Public reports Oregon
Public reports Oregon
Public reports Oregon
State websites Oregon
Utah
Alerts and advisories Utah
Authorizing statutes or regulations Utah
Authorizing statutes or regulations Utah
Authorizing statutes or regulations Utah
Authorizing statutes or regulations Utah
Authorizing statutes or regulations Utah
State website Utah
Tools that enable facilities to conduct analyses Utah
Connecticut
Authorizing statutes or regulations Connecticut
Legislative reports Connecticut
Reportable event forms Connecticut
User's guide for facilities Connecticut
Colorado
Authorizing statutes or regulations Colorado
Authorizing statutes or regulations Colorado
Public reports Colorado
State website Colorado
User's guide for facilities Colorado
District of Columbia
Authorizing statutes or regulations District of Columbia
Public reports District of Columbia
Public reports District of Columbia
Public reports District of Columbia
Reportable event forms District of Columbia
Indiana
Authorizing statutes or regulations Indiana
Authorizing statutes or regulations Indiana
Lists or clarifications of reportable events Indiana
Lists or clarifications of reportable events Indiana
Public reports Indiana
Public reports Indiana
State website Indiana
Kansas
Authorizing statutes or regulations Kansas
Authorizing statutes or regulations Kansas
Reportable event forms Kansas
Maine
Authorizing statutes or regulations Maine
Authorizing statutes or regulations Maine
Legislative reports Maine
Legislative reports Maine
Legislative reports Maine
Legislative reports Maine
Reportable event forms Maine
Reportable event forms Maine
State website Maine
New York
Authorizing statutes or regulations New York
Authorizing statutes or regulations New York
Lists or clarifications of reportable events New York
Lists or clarifications of reportable events New York
Public reports New York
State website New York
Tools for evaluating root causes and contributing factors New York
User's guide for facilities New York
Rhode Island
Authorizing statutes or regulations Rhode Island
Authorizing statutes or regulations Rhode Island
Legislative reports Rhode Island
South Carolina
Authorizing statutes or regulations South Carolina
South Dakota
Authorizing statutes or regulations South Dakota
Authorizing statutes or regulations South Dakota
Authorizing statutes or regulations South Dakota
Tennessee
Authorizing statutes or regulations Tennessee
Authorizing statutes or regulations Tennessee
Lists or clarifications of reportable events Tennessee
Public reports Tennessee
Public reports Tennessee
Reportable event forms Tennessee
Reportable event forms Tennessee
Reportable event forms Tennessee
Reportable event forms Tennessee
State website Tennessee
User's guide for facilities Tennessee
User's guide for facilities Tennessee
Vermont
Authorizing statutes or regulations Vermont
Authorizing statutes or regulations Vermont
Authorizing statutes or regulations Vermont
Authorizing statutes or regulations Vermont
Legislative reports Vermont
State website Vermont
State website Vermont
User's guide for facilities Vermont
Washington
Authorizing statutes or regulations Washington
Authorizing statutes or regulations Washington
User's guide for facilities Washington
User's guide for facilities Washington
Wyoming
Authorizing statutes or regulations Wyoming
Authorizing statutes or regulations Wyoming
Lists or clarifications of reportable events Wyoming
Public reports Wyoming
Public reports Wyoming
Reportable event forms Wyoming
State website Wyoming
California
Authorizing statutes or regulations California
Public reports California
User's guide for facilities California
Ohio
Authorizing statutes or regulations Ohio
Authorizing statutes or regulations Ohio
Reportable event forms Ohio
New Hampshire
Authorizing statutes or regulations New Hampshire
Authorizing statutes or regulations New Hampshire
New Jersey
Lists or clarifications of reportable events New Jersey
Public reports New Jersey
Public reports New Jersey
Reportable event forms New Jersey
Reportable event forms New Jersey
State website New Jersey
Tools that enable facilities to conduct analyses New Jersey
User's guide for facilities New Jersey

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