Effective Date of Rule: Thirty-one days after filing.
Purpose: The rules establish the adverse health event and incident reporting system for psychiatric hospitals, as required by 2SHB 2292 (2006), SB 6457 and E2SHB 3123 (2008). The rules include a list of reportable adverse health events, how and when to report, the inclusion of contextual information and staffing levels at the time of the event, a timeline for reporting confirmed events, the form and content of a root cause analysis and the corrective action plan.
Statutory Authority for Adoption: Chapter 70.56 RCW.
Adopted under notice filed as WSR 08-22-090 on November 4, 2008.
Changes Other than Editing from Proposed to Adopted Version: References to an internet-based reporting system in WAC 246-322-260, which was to be contracted with an independent entity, were removed because funding is not available.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 1, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 1, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 0, Repealed 0.
Date Adopted: March 11, 2009.
Mary C. Selecky
WAC 246-322-260 Adverse health events and incident reporting system. The purpose of this section is to outline each psychiatric hospital's responsibilities for reporting and addressing adverse events. In this section, "serious disability" means a physical or mental impairment that substantially limits the major life activities of a patient.
Psychiatric hospitals must:
(1) Notify the department whenever any of the following adverse events as defined by the National Quality Forum, Serious Reportable Events in Health Care occur:
(a) The psychiatric hospital's name;
(b) The type of event identified in subsection (1) of this section;
(c) The date the event was confirmed; and
(d) Any additional contextual information the hospital chooses to provide.
(3) Conduct a root cause analysis of each adverse event following the procedures and methods of:
(a) The joint commission;
(b) The department of Veterans Affairs National Center for Patient Safety; or
(c) Another nationally recognized root cause analysis methodology found acceptable by the department;
(4) As part of the root cause analysis, include the following information:
(a) The number of patients, registered nurses, licensed practical nurses, and unlicensed assistive personnel present in the relevant patient care unit at the time the reported adverse event occurred;
(b) The number of nursing personnel present at the time of the adverse event who have been supplied by temporary staffing agencies including traveling nurses; and
(c) The number of nursing personnel, if any, on the patient care unit working beyond their regularly scheduled number of hours or shifts at the time of the event and the number of consecutive hours worked by each such nursing personnel at the time of the adverse event.
(5) Create and implement a corrective action plan for each adverse event consistent with the findings of the root cause analysis. Each corrective action plan must include:
(a) How each finding will be addressed and corrected;
(b) When each correction will be completed;
(c) Who is responsible to make the corrections;
(d) What action will be taken to prevent each finding from reoccurring; and
(e) A monitoring schedule for assessing the effectiveness of the corrective action plan including who is responsible for the monitoring schedule;
(6) If a psychiatric hospital determines there is no need to create a corrective action plan for a particular adverse event, provide a written explanation of the reasons for not creating a corrective action plan;
(7) Complete and submit a root cause analysis report, within forty-five days after confirming an adverse health event has occurred, to the department.