Brief Description: Modifying disclosure provisions under the adverse health events and incident reporting system.

Sponsors: Representatives Campbell, Hunt and Kenney; by request of Governor Gregoire.

Hearing Date: 1/21/08

Staff: Chris Blake (786-7392).

Background:

In 2006 the Legislature passed new requirements for the systemic notification and reporting of unsafe events that occur in medical facilities, including hospitals, ambulatory surgical facilities, childbirth centers, psychiatric hospitals, and correctional medical facilities. The unsafe events that are covered by the program include adverse events and incidents. Adverse events are serious reportable events that have negative consequences for patient care as defined by the National Quality Forum and adopted by the Department of Health (Department) through rulemaking. There are two types of incidents: (1) acts that result in unanticipated injury to the patient that are not included in the definition of an adverse event and (2) acts that could have caused unanticipated injury or required additional health services, but did not.

The new program requires that medical facilities notify the Department about the occurrence of an adverse event within 48 hours of confirming that it happened. Within 45 days of the notification, the medical facility must file a detailed report related to the adverse event that includes a root cause analysis and description of a corrective action plan or reasons for not adopting a corrective action plan. Medical facilities have the option of reporting the occurrence of an incident to an independent entity that the Department will contract with to collect and analyze data received through the program.
   
Previous reporting standards required the Department to publicly disclose reports filed by hospitals in accordance with public disclosure requirements. Since adoption of the new notification and reporting system in 2006, public access has been limited to information contained in an annual report that states the number of adverse events and incidents by geographic location.

Summary of Bill:

The intent of the adverse events reporting system is modified to include the goal of assisting the public in making informed health care choices.

The Department is required to make notifications of adverse events and incidents regarding unanticipated injuries available to the public.

The independent entity shall include facility-specific information in its annual reports, including the date and type of each occurrence of an adverse event or incident relating to an unanticipated injury. The reports must also include any information that is relevant to establishing context for health care consumers as determined by the Department. The context information may include the number and acuity level of patients at the medical facility and any efforts to prevent similar adverse events and incidents.

Any information and documents created specifically for and maintained by quality improvement programs and peer review committees that are used to make a notification or report of an adverse event or incident remains confidential and exempt from public disclosure, except that the actual notifications of adverse events and incidents relating to an unanticipated injury are subject to public disclosure requirements. It is specified that reports of adverse events and notifications of incidents that could have caused unanticipated injury or required additional health services, but did not, are exempt from public disclosure requirements.

The requirement that the Department aggregate and withhold the identity of individual medical facilities in the adverse event and incident information that it sends to the Washington State Quality Forum is replaced with a requirement that the information identify individual facilities.

The definition of "incident" is limited to include only serious unanticipated injuries to a patient.

Appropriation: None.

Fiscal Note: Available.

Effective Date: The bill takes effect 90 days after adjournment of session in which bill is passed.