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Medical Errors and Patient Safety


  • •  2000 DOH Rules Start Event Reporting

    Tennessee's mandatory medical error reporting program was developed when Tennessee Rule 1200-8-1-.11 was filed by the Department of Health on March 18, 2000.

  • •  Creation of Public/Private Task Force (TIPS)

    Subsequent to the release in November 1999 of the IOM's To Err is Human: Building a Safer Health System, the Tennessee Department of Health convened a task force that addressed definitions and guidelines for error reporting, and it recruited a Tennessee Improving Patient Safety (TIPS) committee and coalition of volunteer stakeholders. Activity for the TIPS groups officially began in August 2001.

    The combined private-public collaboration recommended revisions in the existing reporting program. Upon the recommendations from TIPS, the legislature passed the “Health Data Reporting Act of 2002,” creating new statute-based definitions for “unusual events” and defining a reporting program designed to create public accountability for medical facilities, while respective of confidentiality. The law was signed by the Governor in March 2002 and promulgated into amendments to existing rules and creation of new rules for all facilities licensed within the Department of Health, including Hospitals (Tennessee Rule 1200-8-1-.11).

    June 2003 marked the beginning of mandatory reporting of over 30 “unusual events.” Simultaneously in 2002 with legislative deliberations, an electronic extranet report system, the Unusual Event Reporting System (UIRS ) was developed within the Department of Health and was implemented before passage of the law.

  • •  Features of the Reporting Program

    Public release of reported “unusual event” data does not identify individual medical facilities nor any individual licensed health professionals involved in these reportable events. The reporting program is designed to provide confidentiality without compromising public accountability. Reporting of aggregate data (without identification of individual facilities) has been provided for 2002 (released May 7, 2003) [PDF] and for 2003 (released in early 2004). In addition, aggregate data is available on a quarterly and annual basis by facility type after 2003.

    The initial experience reveals that the performances of facilities within the state are characterized by under-reporting of “unusual events,” inadequate compliance, and generally inadequate quality of Corrective Action Plans (CAPs) that were developed and submitted to the Department of Health as mandated by statute. While the Department of Health has seen evidence of improvement from 2002 to 2003, some non-compliance has been evident. Whereas a non-punitive posture was adopted in 2002, sanctions against facilities for non-reporting and for late reporting were issued in 2003.

    Tennessee has developed an ambitious medical error reporting program with a technically-sophisticated reporting system. Collaboration between public and private contributors has developed a well-thought reporting program with an extensive number of reportable “unusual events” under the regulatory control of the Department of Health.

    Extensive education and training has characterized an ambitious state-of-the-art effort for translating definitions into reportable information, and the Department of Health has provided resources to evaluate the action plans with an intent to share lessons learned with all facilities. This latter element of the program has yet to be realized due to previously mentioned probelms, incomplete reporting to the UIRS, and logistical problems in the system that remain to be worked out.

    A more detailed history of Tennessee's reporting program is available.

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