Kansas uses ‘reportable incident’ as the reportable event for the patient safety / medical error reporting program. The complete definition of “reportable incident” is provided in K.S.A. 65-4921(f):
(f) “Reportable incident” means an act by a health care provider which: (1) Is or may be below the applicable standard of care and has a reasonable probability of causing injury to a patient; or (2) may be grounds for disciplinary action by the appropriate licensing agency.
A key aspect of this definition is that the “reportable incident” is an act by a health care provider. Kansas does not provide a list of events to define “reportable incident.”
The Kansas definition does not specifically address errors that might be system errors. In this regard, the Kansas definition does not provide a comprehensive approach to medical errors. The philosophy expressed in these regulations appears contrary to recommendations of the IOM report and contrary to characteristics of successful reporting programs that advocate ‘independence’ from any authority with power to punish the reporter or reportee, and ‘non-punitive’ and ‘system-oriented’ approaches to evaluating adverse event reporting.1 From a strictly health-provider perspective, the reporting program implementation has a distinctly punitive flavor, which is consistent with the medical malpractice legislation under which it was formulated.
A March 2003 NASHP publication addressed the issue of adverse event definitions across multiple states. [PDF]2 NASHP systematically compared state definitions against the 27 NQF 'Never' Events. Kansas was represented as having an Adverse Event Reporting program. Kansas was represented as having definitions for 21 of the 27 NQF definitions, and each alleged definition was repeatedly classified in the category "State includes this event but not explicitly."
However, based on Kansas' regulations and documents available from Kansas, this position appears misleading, if not mis-stated. Kansas has neither an adverse event reporting program nor definitions to support it. Kansas has a Health Provider/health professional reporting program that is tied to the ‘reportable incident’ definition. This definition is tied to compliance with a medical malpractice ‘standards-of-care’ concept rather than compliance with a patient safety concept of reportable events.
Indeed, the Risk Management Incident Report Form has spaces for Provider ID and Kansas State certification number [PDF]. In addition, the Quarterly Risk Management Report form that facilities must file with the Burea of Health Facilities includes item #5, which requires a summary of all reported health professionals by licensing agency:
"Specify the number of reports sent to each of the following licensing agencies ... ___ Board of Healing Arts; ___ Board of Nursing; ___ Board of Pharmacy; ___ Other (specify):_____." [PDF]
1 Leape LL, "Reporting of Adverse Events," N Engl J Med, (2002); 347(20):1633-38 [PDF]
2 "Rosenthal J and Booth M, "Defining Reportable Adverse Events: A Guide for States Tracking Medical Errors," National Academy for State Health Policy, GNL50; March 2003. [PDF]