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.
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.
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.
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.
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.
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.
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.
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.
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.
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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.
