Tag Archive for: Medical Malpractice

You are here: Home / Medical Malpractice

Posts

An Act to Reduce Medical Errors and Improve Patient Health: A Case Study from Maine

/in /by

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.

Mandatory_reporting_ME.pdf 119.2 KB

 

State Reporting of Medical Errors and Adverse Events: Results of a 50-State Survey

/in /by

This report describes results of a state survey of legislative and regulatory requirements for reporting medical errors and adverse events in hospital settings. The paper addresses the following: which states require mandatory reporting systems, what type of data is reported, how states use the data, who has access to the data, and the type of technical assistance states need to improve their systems.

Adverse Events Survey 2000 1.2 MB

Patient Safety and Medical Errors: A Road Map for State Action

/in /by

This report provides state executive and legislative branch officials with a framework for considering how they might coordinate with government and private stakeholders to address medical errors and patient safety in their states. The report outlines mechanisms to estimate the number of medical errors that occur and actions that states can take to improve patient safety in their various roles as purchasers, providers, regulators, educators, conveners, and policymakers.

patient_safety_roadmap.pdf 193 KB

 

State Responses to the Problem of Medical Errors: An Analysis of Recent State Legislative Proposals

/in /by

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.


State Responses Medical Errors 753.9 KB

 

State Patient Safety Centers: A New Approach to Promote Patient Safety

/in /by

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.

patient_safety_centers.pdf 354.8 KB

 

The Pennsylvania Learning Exchange: Helping States Improve and Integrate Patient Safety Initiatives Summary Report

/in /by

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.
Pennsylvania’s initiative is a model for developing a comprehensive, interagency approach to address patient safety within a broader context of state health policy and as a critical component of health reform. The Prescription for Pennsylvania coordinates patient safety efforts under an umbrella entity (the Governor’s Office of Health Care Reform) and involves multiple agencies. The learning exchange event focused on Pennsylvania’s innovative strategies, including its successful efforts to call statewide attention to the issue of patient safety; build a case for change; translate data into practice and policy; and create a state infrastructure to address the issue. It also provided an opportunity for visiting state officials to share their own innovations.
The purpose of the learning exchange was to enable state officials to explore policy and operational issues, identify emerging issues, develop policy solutions, and improve state health policy and practice.
Ten Pennsylvania patient safety officials from key state agencies were host officials. Participants included 24 state officials representing eleven states. All visiting officials provided short written summaries of what they gained from the learning exchange and how they planned to apply this new knowledge to their state’s work to improve patient safety.

Pennsylvania Learning Exchange Summary Report 448.2 KB

 

Statewide Patient Safety Coalitions: A Status Report

/in /by

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.

patient_safety_coalitions.pdf 202.9 KB

How States are Responding to Medical Errors: An Analysis of Recent State Legislative Proposals

/in /by

This report summarizes state legislation proposed or enacted in 2000 to address concerns over medical errors and patient safety issues. It includes summaries of 45 pieces of separate legislation.

Medical Errors: An Analysis of Recent State Legislative Proposals 705.3 KB

 

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

/in /by

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:

medical_errors_analysis_secs1-4.pdf 1.2 MB
medical_errors_analysis_secs5-6.pdf 1002.7 KB
medical_errors_analysis_secs7-9.pdf 1.2 MB
medical_errors_analysis_secs10-12.pdf 1.1 MB
medical_errors_analysis_appenda_b.pdf 1 MB
medical_errors_analysis_appendc_d.pdf 628.2 KB
medical_errors_analysis_append_e.pdf 1.2 MB
medical_errors_analysis_appendf_g_h.pdf 1.4 MB

 

Defining Reportable Adverse Events: A Guide for States Tracking Medical Errors

/in /by

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.

Defining Adverse Events 2003 698.7 KB

 

Sign Up for Our Weekly Newsletter

Sign Up for Our Weekly Newsletter

  • This field is for validation purposes and should be left unchanged.

Portland, Maine Office:

2 Monument Square, Suite 910
Portland, Maine 04101

p: 207-874-6524

Washington, DC Office:

1233 20th St., N.W., Suite 303
Washington, DC 20036

p: (202) 903-0101
f: (202) 903-2790

Contact Us

Phone: 202-903-0101

Copyright © 2019, by The National Academy for State Health Policy. All rights reserved. May not be published or otherwise distributed without explicit permission | Privacy Policy | Terms Of Use