Washington has addressed patient safety and medical errors through both public and private initiatives.
- • Coordinated Quality Improvement Program (CQIP)
- ◊ 1993
With dual goals to improve the quality of healthcare and to identify and prevent medical malpractice, the Washington legislature in 1993 created the Coordinated Quality Improvement Program (CQIP). This law required the mandatory participation of hospitals, extending the duties of existing peer review and quality improvement committees to address concerns of medical malpractice [RCW 70.41.200].
Simultaneously, the law extended similar incentives and protections provided to hospitals to other healthcare entities, i.e., licensed medical facilities, professional societies or organizations, health care service contractors, health maintenance organizations, and approved health carriers [RCW 43.70.510(1)(a)] so that they too might voluntarily establish state-approved CQIP plans to improve the quality of health care, and identify and prevent malpractice.
- ◊ 2004
Subsequent amendments to CQIP laws in 2000 and 2004 [SB 6210 | PDF] broadened the definitions of CQIPS to allow as few as 5 providers, while extending whistleblower protections to all informants, broad immmunities from civil action to committee participants, and confidentiality for all documents and data that includes protections from discoverability and introduction into evidence in civil suits.
- ◊ 2005 - 06
Insofar as CQIP defines the tenor of quality improvement and medical malpractice in healthcare, it provides the milieu in which patient safety and medical error reporting programs exist in Washington.
- ◊ 1993
- • Adverse Event Reporting Program
- ◊ 1999
The State of Washington initiated its mandatory adverse event reporting program in 1999 when the Washington State Department of Health [DOH] adopted state licensing rules that require hospitals to report adverse events within 2 business days of the event being confirmed by the hospital. The list of 8 definitions translated to 12 discrete adverse events, four of which precisely match JCAHO ‘reportable sentinel events.’
- ◊ 2000
In 2000 the state legislature enacted EHB 1711 [HTML | PDF] addressing hospital disclosure. As part of this legislation, the results of annual licensing inspections and complaint investigations can be disclosed publicly, even though the reported adverse events are not reported publicly. Every adverse event notification and complaint the Department of Health receives concerning patient well-being was investigated. Hospitals were required to post the department's toll-free complaint number. While hospitals were identified, there was no identification of patients or health professionals involved in the care. The confidentiality and discoverability of peer review and quality improvement documents reviewed by the department and accrediting organizations are clearly protected. No transparency of aggregate reported events at a public website or via periodic state publications exists.
- ◊ 2005
One facet of transparency that Washington did embrace in 2005 was a mandate that all hospitals institute procedures to assure that " . . . information about unanticipated outcomes is provided to patients or their families or any surrogate decision makers . . ." As such, Washington becomes the 10th state to implement laws or administrative rules mandating notification of the patient or the patient's family of adverse events (RCW §70.41.380).
- ◊ 2006
June 7, 2006 marks the effective date of HB 2292 that overhauled the existing reporting system, which had been criticized since its inception for ambiguous event definitions, widespread under-reporting, and differential reporting bias across institutions.
Washington completely revamped the WA reporting program by abandoning prior reporting standards and adopting a 'patient safety center' model in which newly defined adverse events (patterned upon the NQF 27 ‘never events’ definitions) are reported to the DOH, while these same NQF adverse events and incidents, reflecting ‘near-miss’ events and other unexpected non-NQF events, are reported to a single newly created Patient Safety Organization (PSO) that is consistent with the federal legislation.1 Other key features of the reporting program include:
- √ Root cause analysis and Corrective Action Plans are submitted to the DOH for adverse events only
- √ Creation of Internet reporting system for ALL reporting
- √ Confidentiality of all adverse event and incident reporting that precludes identification of any facility (a major change in accountability)
- √ Collection, analysis, and evaluation of adverse event and incident (near miss) data by the PSO [yet to be designated by the DOH in July 2006], which becomes the de facto Washington Patient Safety Center,
- √ Annual reports of aggregrate data to the governor and legislature
The legislation creating the new reporting system evolved from a gubernatorial pow-wow that included malpractice attorneys, providers, and insurers in efforts to overcome years of contentious legislative impasse on medical malpractice reform by seeking to balance "patient safety," "insurance industry reform," and "civil liability reform." These meetings generated a template for the legislation, WA Law (2006), ch 6 [HTML – PDF].
The pre-existing 12 Washington events adopted in 1999 encompassed 7 of the 27 NQF "never-events," and approximately 30% of all events reported in Washington prior to 2006 are NQF reportable events. Comparative information will not be available from the new reporting system until 2009, but only aggregate facility data and no public accountability of individual facilities (or any public identification of facilities) is integrated into the legislation.
In July 2006, the Washington DOH continues to formulate the regulations and establish the requirements for the contracting PSO-like entity that will manage the Washington adverse event and near-miss data.2
1 The Patient Safety and Quality improvement Act of 2005 [P.L. 109-41] that was signed into law on July 29, 2005, establishes voluntary, confidential, and non-discoverable reporting of adverse events / medical errors to non-federally funded Patient Safety Organizations, which will function as the the entities through which voluntary reporting is channeled. In early 2006, AHRQ continues to define the PSO implementation standards.
2 The fiscal notes that accompanied the law that sets up the independent PSO-like entity, indicates that the DOH
". . . starting in FY07 would be required to contract with a qualified independent entity at an estimated at $145,000 per year (966 hours at $150 per hour). The independent entity would be required to perform all the activities listed above and report the activities under this chapter to the Governor and Legislature no later than January 1, 2008, and annually thereafter."
"For the development and implementation of an internet-based reporting system the department is estimating $15,000 for start up costs in FY07 and $3,000 annually thereafter for maintenance of the internet-based reporting system."
Given that other states [e.g., OR, FL, MD, PA] are spending $500,000 to $2.5M annually to achieve the same result, it is unclear if the State of Washington PSO entity will be adequately funded or if the legislature or the DOH will create other sources of income (e.g. facility assessments) to raise the level of support.
- ◊ 1999
- • Medication-related Errors
- ◊ 2000
The state legislature in 2000 passed ESHB 2798, directing the Department of Health, in consultation with the Board of Pharmacy and professional licensing boards of providers with prescribing authority, to develop and submit recommendations on methods for reducing medication-related errors. As directed by the law, [ESHB 2798, §(4)] the DOH report to the legislature was submitted by December 31, 2000. The DOH report provides analyses and recommendations for addressing medication-related errors and patient safety issues. A synopsis of that report includes a list of 23 recommendations for the reduction of medication-related errors.
Among these recommendations in the 2000 DOH report, were extensions to the coordinated quality improvement program (CQIP) permitting sharing of information and documents with other CQIP-approved programs [RCW 43.70.510(6)] that were approved in 2004. [ESSB 6210 → Chapter 145, Laws of 2004]
- ◊ 2006
A feature that was tucked into the complex patient safety bill HB 2292 that passed in 2006 was a redefinition of ‘legible prescription.’ Under the guise of reducing medication-related errors, the new law changed the definition, adding the underlined text below:
"‘legible prescription’ means a prescription or medication order issued by a practitioner that is capable of being read and understood by the pharmacist filling the prescription or the nurse or other practitioner implementing the medication order. A prescription must be hand printed, typewritten, or electronically generated."
A consequence of this law is that pharmacists have become unwitting and unpopular enforcers, with the power to reject illegible prescriptions or legible prescriptions written in cursive.
- ◊ 2000
- • Public/Private Initiatives
Since 2002, Washington also has had the broad-based support of the Washington State Patient Safety Coalition (WSPC), a voluntary public/private organization supported by healthcare organizations, healthcare professional organizations, businesses, and the Washington State Department of Health (DOH) and the Washington State Health Care Authority (HCA). Its central activities includes projects and educational efforts addressing medical errors and enhancing patient safety.
- • Non-public Initiatives
Washington has other organizations and entities supporting patient safety measures besides public programs. The Washington State Hospital Association (WSHA) announced a major patient safety initiative in June 2004. All member hospitals were asked to participate and comply with JCAHO's 7 National Patient Safety Goals for 2005 and participate in the Institute for Healthcare Improvement (IHI) ‘100K Lives Campaign.’ The WSHA will undoubtedly take a significantly pro-active role in multiple patient safety initiatives through 2006 and beyond, and the WSHA has announced its intent to collaborate with the Washington State Medical Society (WSMA) on some initiatives. WSMA also has independent patient safety initiatives targeting physicians and patients.