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Nonpayment for Preventable Events and Conditions: Aligning State and Federal Policies To Drive Health System Improvement
NASHP synthesized background information about state and federal policies that deny or reduce payment for adverse events. In October 2009, NASHP convened high-level state and national leaders to discuss 1) issues related to nonpayment of adverse events and 2) priority issues for state/federal dialogue. This report examines policies implemented by the Medicare program and state agencies in twelve states (Colorado, Kansas, Maine, Maryland, Massachusetts, Minnesota, Missouri, New Jersey, New York, Oregon, Pennsylvania and Washington). Key lessons are included. Participants see aligning federal and state nonpayment policies as one area in which future alignment between federal and state policies can advance health system reform.December 2009» -
2007 Guide to State Adverse Event Reporting Systems
Since the Institute of Medicine called for a nationwide, mandatory reporting system to provide for the collection by state governments of standardized information about adverse medical events, much state activity has focused on the development and refinement of these systems. The information collected can help identify health system weaknesses, complement other state functions, and help safeguard health-care consumers.December 2007 -
Maximizing the Use of State Adverse Event Data to Improve Patient Safety, Brief
This news brief reviews key findings from a meeting of state officials that focused on efforts to improve data integrity, event report analysis, and data feedback and dissemination. The report examines these issues and identifies a number of challenges and opportunities that states encounter as they attempt to improve their databases and the usefulness of the data for improving patient safety. Eleven states participated in the summit: Florida, Georgia, Maine, Maryland, Massachusetts, Minnesota, Nevada, New York, Oregon, Pennsylvania, and Utah. The report contains a number of tools and resources that have been developed by the participating states.December 2005 -
Maximizing the Use of State Adverse Event Data to Improve Patient Safety
This report reviews key findings from a meeting of data collectors (state officials who administer reporting systems), analysts (state officials or consultants to them), and users (providers, purchasers, and consumers). The meeting was held to identify mechanisms to improve reporting, tools used for event report analysis and dissemination, and opportunities for improvement. This report reviews key findings from the meeting to assist states in improving their reporting systems and to encourage providers to improve the quality of the required reports so that data are credible and useful in shaping patient safety improvement interventions. It focuses on data integrity, event report analysis, and data feedback. The report also raises a number of challenges and opportunities that states encounter as they attempt to improve their databases and the usefulness of the data for improving patient safety.October 2005 -
How States Report Medical Errors to the Public: Issues and Barriers
This paper explores how data from mandatory reporting systems are (or can be) disclosed to the public. Based upon detailed interviews with states that have mandatory reporting systems, NASHP identified critical junctures in the design of reporting systems that influence the ultimate use of data. By examining and mapping out these critical junctures, the parameters of existing reporting systems can be better understood, and the intent of new reporting systems can be made more explicit and viable.
This report examines the protection and disclosure of mandatory reported data with a focus on:
October 2003 -
Defining Reportable Adverse Events: A Guide for States Tracking Medical Errors
This report was developed to help policy makers develop, refine, and clarify mandatory reporting systems and potentially to compare their data nationally. The guide includes a comparison of the National Quality Forum’s (NQF) list of serious reportable events to existing state reporting systems and discusses further steps recommended by states to support the use and consistent implementation of the NQF list.March 2003 -
An Act to Reduce Medical Errors and Improve Patient Health: A Case Study from Maine
Among recommendations to address medical errors, the Institute of Medicine (IOM) called for the creation of a nationwide mandatory reporting system for adverse events that result in death or serious injury, implemented through state collection of standardized data. This briefing reviews the system in Maine. Health care facilities are required to report sentinel events to the state Department of Human Services Division of Licensure and Certification. The Division reviews the events and takes appropriate action. Reports are confidential and privileged, and reporters are immune from liability for reporting events. The Division will develop an annual report of summary data. Facilities that knowingly violate the act are subject to fine. Funding for two positions and information system development was provided.August 2002» -
How Safe Is Your Health Care? A Workbook for States Seeking to Build Accountability and Quality Improvement Through Mandatory Reporting Systems
This comprehensive workbook provides a step-by-step guide to help state policy makers build or redesign a mandatory reporting system. The workbook provides an overview of the various policy goals and considerations that frame states' mandatory reporting systems. It is designed to enable states to learn from the success of other states and, at the same time, avoid the pitfalls they may have experienced in building their systems. This publication is available in three separate sections for download.November 2001 -
Cost Implications of State Medical Error Reporting Programs: A Briefing Paper
This paper examines the costs of designing and implementing a state-based mandatory reporting system for adverse events that occur within hospitals. The paper begins with a brief review of the Institute of Medicine’s study on medical errors and its recommendations regarding the role of states in addressing the issue. This is followed by a summary of existing state mandatory reporting programs as well as barriers perceived by states without reporting programs. A description of the two states whose programs were studied for this paper is then presented, including an analysis of how variations in program features impact cost.May 2001 -
State-based Mandatory Reporting of Medical Errors: An Analysis of the Legal and Policy Issues
This report explores data issues associated with mandatory reporting systems, potential interactions between mandatory reporting and malpractice litigation, the potential uses of publicly available mandatory reporting system data, and arguments for and against protections for such data.
Click here to download the zipped pdf file.
March 2001
