Current State Programs Addressing Medical Errors: An Analysis of Mandatory Reporting and Other Initiatives

Based on interviews with state and hospital officials, professional boards, providers, consumer representatives, and purchasers, this report places mandatory reporting within the context of current state and federal hospital oversight activity. It provides detailed information about how eight state-based mandatory hospital reporting programs came into existence, how these programs are operated, the associated legal issues, and other state-base initiatives aimed at improving patient safety. Contents  Introduction  National Overview of the Hospital Oversight Environment: The Relationship Between State and Federal Efforts  Project Overview  Site-visit States’ Hospital Quality Oversight Policies and Practices  Background, Origins, and Evolution of Reporting Requirements  Nuts and Bolts of Reporting Requirements  Data Management and Integrity  Analysis and Use of the Data  Legal Protections for Reported Information  Other Patient Safety Activities and Initiatives  Findings  Conclusion  Appendix A: Mandatory Reporting Requirements for Hospital-based Adverse Events Maintained in State Agencies that License Hospitals  Appendix B: Expert Panel Membership  Appendix C: Summaries of Phone Interviews  Appendix D: Site-visit Protocols  Appendix E: State Reporting Requirements  Appendix F: New York State’s List of Events Requiring Root Cause Analysis  Appendix G: Stakeholder Initiatives  Appendix H: Patient Advocate Newsletter Download this publication in sections:

Attachment	Size
medical_errors_analysis_secs1-4.pdf	1.2 MB
medical_errors_analysis_secs5-6.pdf	1002.74 KB
medical_errors_analysis_secs7-9.pdf	1.19 MB
medical_errors_analysis_secs10-12.pdf	1.06 MB
medical_errors_analysis_appenda_b.pdf	1.04 MB
medical_errors_analysis_appendc_d.pdf	628.2 KB
medical_errors_analysis_append_e.pdf	1.22 MB
medical_errors_analysis_appendf_g_h.pdf	1.36 MB