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
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