SB 6457

SENATE BILL REPORT
SB 6457

This analysis was prepared by non-partisan legislative staff for the use of legislative members in their deliberations. This analysis is not a part of the legislation nor does it constitute a statement of legislative intent.

As Reported By Senate Committee On:
Health & Long-Term Care, February 04, 2008

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.

Majority Report: That Substitute Senate Bill No. 6457 be substituted therefor, and the substitute bill do pass.Signed by Senators Keiser, Chair; Franklin, Vice Chair; Pflug, Ranking Minority Member; Carrell, Fairley, Kastama, Kohl-Welles and Marr.

Background: Adverse health events are required to be reported by medical facilities to the Department of Health (DOH) as the result of legislation passed in 2006. The Legislature's intent was to establish an adverse health events and incident reporting system designed to facilitate quality improvement in the health care system, improve patient safety, and decrease medical errors in a nonpunitive manner.

Adverse health events are those serious reportable events listed by the National Quality Forum. They include for example, events like: performing surgery on the wrong body part, leaving a foreign object in a patient after surgery, or abduction of a patient.

An incident is defined as an event which results in unanticipated injury to a patient in a medical facility, that is not related to the natural course of the patient's illness or underlying condition and does not constitute an adverse event. An incident can also be an event which could have injured the patient but did not or did not require additional health care services to the patient.

The adverse health events and incident reporting system includes initial notification of the adverse event to the DOH as well as a root cause analysis of the event and a corrective action plan. Provision is made for the DOH to communicate with the Washington state quality forum about adverse events and incidents without identifying individual medical facilities. Notification of adverse events and notification of incidents causing serious injury are currently exempt from public disclosure.

Summary of Bill (Recommended Substitute): The contracted independent entity that is responsible for the annual activities report to the Governor and Legislature will report the number of adverse events and incidents in the aggregate, along with a summary of actions taken by facilities, and best practices to promote patient safety.

The adverse event notification or report can be amended within 60 days of submission.

A report of an adverse event or notification of an incident through a quality improvement or peer review committee is exempt from public disclosure under the Public Records Act. A notification of an adverse event is not exempt from public disclosure under the Public Records Act and must include context information if the medical facility chooses to provide it.

EFFECT OF CHANGES MADE BY HEALTH & LONG-TERM CARE COMMITTEE (Recommended Substitute): The activities report to the Governor and the Legislature will report the information in the aggregate, not by facility.

The definition of incidents does not require that the injury suffered be "serious" to be considered an incident.

The adverse event notification or report can be amended within 60 days of submission.

A report of an adverse event or notification of an incident through a quality improvement or peer review committee is exempt from public disclosure under the Public Records Act. A notification of an adverse event is not exempt from public disclosure under the Public Records Act and must include context information if the medical facility chooses to provide it.

Effective Date: The bill contains several effective dates. Please refer to the bill.

Staff Summary of Public Testimony on Original Bill: PRO: The Governor supports transparency in the delivery of health care and has worked with stakeholders on this bill. We have a proposed substitute bill.

Persons Testifying: PRO: Jonathan Seib, Office of the Governor, Lisa Thatcher, Washington State Hospital Association.