Adverse Event Reporting Tools by State

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.

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.

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.

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).

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 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.

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.

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."

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.

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.

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 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.