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


  • •  Definition of ‘Sentinel Event’

    For the Patient Safety Sentinel Event Reporting program, the definition of ‘patient safety sentinel event’ is provided in R380.200(3-2) of Utah's administrative code. Patient safety sentinel events include:

    • (a) all deaths in the facility that are directly related to clinical service or process provided to a patient as long as the patient:
      • (i) was not subject to a "do not resuscitate" order at the time of death;
      • (ii) was not in a critical care unit at the time of death, (except when transferred from within the hospital to the critical care unit because of a patient safety sentinel event)
      • (iii) was not in the emergency room or operating room at the time of death after presenting in the last 24 hours with a Glasgow score of 9 or lower
    • (b) events that occur in the facility and that are directly related to any clinical service or process provided to a patient and which result in:
      • (i) surgery on the wrong patient or wrong body part;
      • (ii) suicide of a patient; or
      • (iii) major loss of physical or mental function not related to the natural course of the patient's illness or underlying condition; and
    • (c) events that occur in the facility and that are not directly related to clinical services provided to a patient and which result in an alleged:
      • (i) patient abduction;
      • (ii) discharge of an infant to the wrong family;
      • (iii) rape of a patient;
      • (iv) intentional injury to a patient, whether by staff or others; or
      • (v) suicide of a patient.
  • •  Definition of ‘Adverse Drug Event’

    For the Health Care Facility Patient Safety Program, the reportable event is the ‘adverse drug event.’ The definition of “adverse drug event” as provided in R380.200(2), is

    ". . . any event involving a medication that causes or leads to patient harm, while the medication is in the control of the facility. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.”

    However, the requirement of R3820-210(3) to identify patients with ‘adverse drug events’ according to ICD-9 codes required further refinement and finalization of the classification of adverse events ICD-9-CM Codes. Fortunately for Utah, the Utah DOH received a 3-year AHRQ grant, and this Patient Demonstration project was used to fund a 3-year study on Adverse Events. For the ‘adverse drug event’ component of the study, an involved process that reviewed 1,091 ICD-9 codes and required input from an extensive expert panel (fifteen physicians, four medical record coders, three pharm Ds, and one attorney) and staff culminated in an Expert Panel Report [PDF]. Other in-depth documents are available.

    The instances of these ‘adverse drug events’ have been measured according to the ICD-9 codes determined by the expert panel, and these codes have been abstracted from UB-92 administrative hospital inpatient discharge records submitted to the Utah Department of Health. These ICD-9 codes provide retrospective diagnoses that are provided only after the medical chart has been abstracted by the one of the medical records coders and well after the episode of patient care has occurred. What, if any, significant changes in implementation of this rule occurs after the funding for the AHRQ grant terminates is purely speculative.

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