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– TENNESSEE –
Public and Private Policy
Medical Errors and Patient Safety

Rationale

Prior to the issuance of the Institute of Medicine's report, To Err is Human: Building a Safer Health System, in November 1999, Tennessee facilities reported unusual events, and they were reviewed, investigated when necessary, then placed in a file by the Department of Health. The Department did not tabulate any monthly or annual totals.

Following the release of the IOM report in November 1999, Tennessee perused recommendations from private organizations and national accrediting organizations such as The Joint Commission on Accreditation of Healthcare Organizations and the National Quality Forum. In an effort to improve the program and respond to the challenges of the IOM report, the DOH convened a task force of concerned individuals to define terms, identify issues, and develop guidelines. Representatives from facilities, surveyors, nurses, administrators, and attorneys served on this task force, which worked on defining ‘unusual event.’ Its work extended into 2001, coalescing with the formation of the TIPS committee in August 2001.

While Tennessee began tracking unusual events in the year 2000, the work of the task force extended overr several months of exhaustive meetings. This group laid the foundation for legislative action and provided groundwork for the realization that the state needed a better system to improve the quality of health care in Tennessee, and it led to the passage of the Health Data Reporting Act of 2002 that modified the reporting program, including the definitions of unusual events.

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