Title: An act relating to the adverse health events and incident reporting system.

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

Sponsors: By Senate Committee on Health & Long-Term Care (originally sponsored by Senators Keiser and Kohl-Welles; by request of Governor Gregoire).

Brief History:

Health Care & Wellness: 2/20/08, 2/27/08 [DP].

Floor Activity:

Passed House: 3/4/08, 93-0.

HOUSE COMMITTEE ON HEALTH CARE & WELLNESS

Majority Report: Do pass. Signed by 13 members: Representatives Cody, Chair; Morrell, Vice Chair; Hinkle, Ranking Minority Member; Alexander, Assistant Ranking Minority Member; Barlow, Campbell, Condotta, DeBolt, Green, Moeller, Pedersen, Schual-Berke and Seaquist.

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 reporting 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 reporting 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 a 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 reporting program, but the reporting of incidents is not required.

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 notification and reporting system is expanded to include the goal of assisting the public in making informed health care choices.

Notifications of adverse events are subject to public disclosure. Notifications of adverse events must contain the date of the event, the type of event, and any additional contextual information that the facility chooses to provide. Notifications and reports of adverse events may be amended within 60 days of submission.

The annual reports of the independent entity shall contain aggregated information reported on a geographic basis. It is clarified that the report shall include a summary of actions taken by facilities in response to adverse events and incidents. The report shall also include aggregated information for consumers and providers about best practices and prevention tools that medical facilities are implementing to prevent adverse events as well as other patient safety initiatives.

Appropriation: None.

Fiscal Note: Not requested.

Effective Date: The bill takes effect 90 days after adjournment of session in which bill is passed, except section 5 which reinstates prior law related to exemptions from the Public Records Act after a scheduled expiration and takes effect July 1, 2009.

Staff Summary of Public Testimony:

(In support) This bill is a step toward making sure that there is public disclosure of adverse events that occur in medical facilities while creating a culture of openness in quality improvement committees.

(Opposed) None.

Persons Testifying: Senator Keiser, prime sponsor; and Jonathan Seib, Office of the Governor.

Persons Signed In To Testify But Not Testifying: None.