- ACA Implementation & State Health Reform
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- Acute Care
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- Quality, Cost, and Health System Performance
- ACOs
- Adverse Event Reporting
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- Delivery System Reform
- Fraud and Abuse
- Health Care Workforce
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- Managed Care
- Medical Homes & Health Homes
- Medical Malpractice
- Patient Safety
- Payment Reform
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- Specific Populations
- Adolescents
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The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives Summary Report
According to the Institute of Medicine (IOM), preventable medical errors are a leading cause of death in the United States. Yet, state officials who focus on patient safety have few venues to meet, share innovative strategies, and problem solve with each other because patient safety initiatives originate in a variety of state agencies. This report summarizes the Pennsylvania Learning Exchange, an event that brought state officials to Pennsylvania in September 2007 to learn about the state’s successes, challenges, and key elements of its patient safety initiatives. The event was supported by the Commonwealth Fund.December 2007 -
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 -
The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives
According to the Institute of Medicine (IOM), preventable medical errors are a leading cause of death in the United States. Yet, state officials who focus on patient safety have few venues to meet, share innovative strategies, and problem solve with each other because patient safety initiatives originate in a variety of state agencies. This report summarizes the Pennsylvania Learning Exchange, an event that brought state officials to Pennsylvania in September 2007 to learn about the state’s successes, challenges, and key elements of its patient safety initiatives. The event was supported by the Commonwealth Fund.December 2007 -
State Patient Safety Centers: A New Approach to Promote Patient Safety
As of 2004, six states (FL, MD, MA, NY, OR, PA) have enacted legislation supporting the creation of state patient safety centers to help address the problem of medical errors. This report examines the various models states have adopted in designing these centers and includes discussions of how the centers operate and monitor performance. The report also summarizes recommendations from center staff to other states that may be interested in following in their footsteps.October 2004 -
Medical Malpractice and Medical Error Disclosure: Balancing Facts and Fears
This policy brief addresses the issues raised by the convergence of medical error reporting and the fear of medical malpractice litigation. It discusses how states protect data with the intention of increasing the compliance level of reporting, examines a sample state protection statute, and explores recent proposals for alternatives that would address the reluctance of many providers to report for fear of possible malpractice litigation.December 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» -
The Medical Malpractice Insurance Crisis: Opportunity for State Action
A third malpractice insurance crisis in as many decades provides states with an opportunity to take an inclusive approach to the problem by addressing patient safety and medical errors in addition to tort reform. This paper examines the history and causes of the problem, analyzes the various approaches states are taking to solve this most recent crisis, and summarizes Pennsylvania's comprehensive new legislation that links patient safety and tort reform.July 2002» -
Statewide Patient Safety Coalitions: A Status Report
In 12 states, providers, purchasers, consumers, and regulators have recognized the value of coordinating their efforts and have formed statewide public/private patient safety coalitions. These coalitions are educating health care professionals, purchasers, consumers, and policy makers about the nature of medical errors, the culture of safety, and strategies for reducing risks. The seven most mature coalitions are profiled in this report. Coalition members share lessons learned in membership development, communication, successful activities, and building trust.May 2002 -
State Responses to the Problem of Medical Errors: An Analysis of Recent State Legislative Proposals
This report analyzes the 61 medical error-related bills introduced by state policy makers in 2001. It also provides up-to-date information on bills introduced or enacted during the 1999 and 2000 sessions, including information on how states are implementing laws enacted in 1999 and 2000. State proposals to reduce medical errors fall into eight categories, reflecting the key strategies state policy makers are using to address the problem in their respective jurisdictions. These strategies include: system-wide analysis; reporting systems; conditions of licensure; medication error reduction; minimum staffing requirements; financial incentives; appropriations; and public disclosure requirements.February 2002
