- • Hospital Definitions
Georgia has two sets of definitions for reportable 'patient incidents' vs. 'sentinel events' for hospitals. The GHA-sponsored Partnership for Health and Accountability (PHA) program that began in 2000 requires a separate list of reportable events [adapted from JCAHO's Reviewable Sentinel Events that are reported as part of the PHA's Accountability and Health Safety (A&HS) Committee definitions [PDF].
Mandatory reporting of ‘Patient incidents’ began March 12, 2003 with the Department of Human Resources rules for hospitals. Initially only 7 events (including 3 environmental events) were required, but by December 12, 2005, a total of 14 discrete events must be reported. The ORS provides some assistance with interpretation and reporting via their FAQ website. In addition The table below provides the links to the interpretive assistance and reveals the partial mismatch between the two lists.
The PHA program adopts JCAHO's reviewable events that are subject to review according to the Joint Commission's Sentinel Event Policy. There is duplication of reporting of 6 events between the two programs (unanticipated death, injury with loss of function, rape, surgery – wrong patient, surgery – wrong site, and discharge of infant to wrong family). The differences in definitions for rape, injury with loss of function, and unanticipated death likely would identify slightly different cohorts of patients.
– Comparison of Definitions –
GHA-sponsored PHA Program vs.
Georgia Department of Human Resources (DHR) Regulations
1. JCAHO's ‘Reportable Sentinel Events’
2. GHA-sponsored Partnership for Health and Accountability (PHA): ‘Sentinel Events’ [PDF]
3. Department of Human Resources (DHR): Hospital ‘Patient Incidents’ [OCRR § 290-9-7-.07(2)]
The Department of Human Resources rules and regulations were effective on December 12, 2002. [Chapter 290-9-7-.07(2)(a)] Reporting of the first three types of patient incidents began 90 days after the initial effective date of the rules and regulations ( March 12, 2003). Reporting of siix additional types of patient incidents to the Department were required to begin no later than December 12, 2005.
In addition to reportable incidents, the voluntary PHA program also includes reporting of 'near-misses'.
- • Dialysis Unit and Clinical Laboratory Definitions
The Department of Human Services has separate definitions in the rules for End-Stage Renal Dialysis (ESRD) facilities and for Clinical Laboratories. Five of the 7 definitions for ESRD facilities are unique to ESRD facilities; only ‘unanticipated death’ and ‘equipment malfunction | misuse’ are common with reportable hospital events.
Of the 3 reportable clinical lab events, the ‘transfusion’ event is similar to the PHA event, and the ‘Environmental event / utility failure’ is similar to the DHR event definition for hospitals.
The ESRD Incident Reporting Form [PDF] and instructions for completing it are available. Hospital Reporting Forms are available for environmental events [PDF], while ‘Patient Incidents’ [PDF] and the instructions to complete them [PDF] are outdated and do not include all events that are reportable by December 12, 2005. Clinical laboratory incident reporting forms are unavailable in early 2006.