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

Definitions

  • •  Pre-2006 Event Reporting Program – Reportable ‘Events’ Definitions

    The definitions of reportable ‘events’ that were implemented in 1999 were based in part upon JCAHO definitions and are provided in WAC 246-320-145(10). The list of 8 items comprises 12 discrete reportable events including:

    • ◊  an unanticipated death or major permanent loss of function, not related to the natural course of a patient's illness or underlying condition; [2 events]
    • ◊  a patient suicide while in the hospital;
    • ◊  an infant abduction or infant discharge to the wrong family; [2 events]
    • ◊  sexual assault or rape of a patient or staff member; [2 events]
    • ◊  a hemolytic transfusion reaction secondary to blood or blood products incompatibilities;
    • ◊  surgery on the wrong patient or wrong body part; [2 events]
    • ◊  a failure or major malfunction of a facility system, (e.g., heating, ventilation, fire alarm, fire sprinkler, electrical, electronic information management, water supply which affects any patient diagnosis, treatment, or care service within the facility);
    • ◊  or a fire which affects any patient diagnosis, treatment, or care area of the facility.
  • •  Post-2006 Washington Reportable Event Definitions

    The passage of HB 2292 as Chapter 6, WA laws of 2006 [PDF] created major changes in the reporting program and reportable event definitions. The law became effective on June 7, 2006.

    However, as part of the implementation process, the Facilities and Services Licensing (FSL) within the DOH will begin rulemaking procedures to implement the law.

    The two key event definitions changes are defined in WA Law 2006, c.6 §105:

    • (1)  ‘Adverse Event’ or ‘Adverse health event’ means the list of serious reportable events adopted by the national quality forum in 2002, in its consensus report on serious reportable events in health care. The department shall update the list, through adoption of rules, as subsequent changes are made by the national quality forum. The term does not include an incident."
    • ...  
    • (8)  Incident means an event, occurrence, or situation involving the clinical care of a patient in a medical facility that:
      • (a)  Results in unanticipated injury to a patient that is not related to the natural course of the patient's illness or underlying condition and does not constitute an adverse event; or
      • (b)  Could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient.

      ‘Incident’ does not include an adverse event.

    Because the NQF definitions of serious reportable events are so restrictive, the definition of ‘incidents’ will include all adverse events causing injury that are not included within the NQF definitions, i.e., (8)(a) in definition above, plus all ‘near misses’ i.e., (8)(b) in definition above.1

    Reporting of both events is mandatory. The NQF adverse events must be reported by Internet to both the Facilities and Services Licensing (FSL) and the Patient Safety Organization-like independent entity, whereas the ‘incidents’ must be reported only to the independent entity.


  • 1   The States of Connecticut and Minnesota are the only States that in 2006 have published NQF adverse events. For both states the reported population-indexed incidence is remarkably similar at 14.4 NQF events/100,000 admissions and 14.6 NQF events/100,000 admissions AND 2.9 NQF events/100,000 patient-days and 3.2 NQF events/100,000 patient-days. [see CT website and MN website]

        From 1999 through 2005, Washington has reported 5 of the NQF's 27 events including ‘wrong site surgery’ and ‘wrong patient surgery.’ Washington hospitals reported 58 such events over a 6 year period (1999-2005), whereas Minnesota hospitals have reported 28 such events over a 27+ months of 2004-2005, which is 75% more than what is reported in Washington.

        CHARS data from 2000-2005 reveals an average LOS ~ 3.82 days compared to 4.61 for Minnesota. In addition, Washington reports slightly fewer annual hospital admissions despite 15% greater population than Minnesota. Therefore, one cannot assume that Washington's reporting would be identical to CT and MN.

        Depending on whether Washington's NQF events are reported proportionately to population or proportionately to population-based events/100,000 admissions, Washington hospitals should anticipate reporting no more than 100-125 adverse events per year. It is unlikely that mandatory reporting by other facilities would increase this number more than 5%, based on experiences in other States.

  • •  Comparison of Washington and JCAHO's Events
    • ◊  ‘Sentinel Event’ – name of reportable event in Joint Commission on Accreditation of Healthcare Organizations (JCAHO) medical error reporting programs.
    • ◊  JCAHO list used to select Washington DOH definitions – the 12 reportable events above were partially adopted from the JCAHO list of sentinel events.
    • ◊  Washington hospitals use both definitions – 59 of Washington's 96 community general hospitals participate in JCAHO's accreditation process and its voluntary sentinel event reporting program. The 59 hospitals, together with the 37 non-JCAHO accredited hospitals, also participate in the Washington State DOH mandatory reporting program. [source: WSHA Power-Point file].
    • ◊  JCAHO has no single standard for reporting – definitions not consistently applied across all organizations
      • √  Hospitals create own reportable events list – Within the JCAHO accreditation process, the JCAHO policy on Sentinel events permits hospitals and organizations to define what constitutes a ‘Reportable Sentinel Event,’ i.e., JCAHO policy permits hospitals to choose the events it will report. [JCAHO website].
      • √  JCAHO ‘Reviewable’ Sentinel Events – JCAHO provides to hospitals a list of ‘Reviewable Sentinel Events,’ which is a subset of sentinel events that is subject to review by the Joint Commission. [JCAHO website].

The table below compares ‘reviewable’ JCAHO sentinel events and the Washington State events.

Comparison of JCAHO and State of Washington
Definitions of Reportable Events
JCAHO Definitions
‘Reviewable Sentinel Event’
WASHINGTON STATE
‘Event’ Definitions
DEFINITION
Similarity Score*
(1)  An unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition
(a)  An unanticipated death or major permanent loss of function, not related to the natural course of a patient's illness or underlying condition
4 of 4
(2)  Suicide of any individual receiving care, treatment or services in a staffed around-the-clock care setting or within 72 hours of discharge
(b)  A patient suicide while the patient was under care in the hospital
2 of 4
(3)  Unanticipated death of a full-term infant
 
0 of 4
(4)  Abduction of any individual receiving care, treatment or services
(c)  An infant abduction or discharge to the wrong family
2 of 4
(5)  Discharge of an infant to the wrong family
4 of 4
(6)  Rape
(d)  Sexual assault or rape of a patient or staff member while in the hospital
1 of 4
(7)  Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities
(e)  Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities
4 of 4
(8)  Surgery on the wrong individual or wrong body part
(f)  Surgery performed on the wrong patient or wrong body part
4 of 4
(9) Unintended retention of a foreign object in an individual after surgery or other procedure.
 
0 of 4
 
(g)  A failure or major malfunction of a facility system such as the heating, ventilation, fire alarm, fire sprinkler, electrical, electronic information management, or water supply which affects any patient diagnosis, treatment, or care service within the facility
0 of 4
 
(h)  A fire which affects any patient diagnosis, treatment, or care area of the facility.
0 of 4
* Definition Similarity Scoring:
0 = No Similarity or No Matching Definition
1 = Minimal Similarity
2 = Moderately Different Definition
3 = Slightly Different
4 = Same Definition
    • ◊  Summary Conclusions re: JCAHO vs, Washington Events Definitions
      • √  Only four identical pairs of definitions
      • √  Washington does not include two of the JCAHO events [(3) and (9)], and it adds the Environmental Events (g) and (h)
      • √  the definitions of suicide: [(2) vs. (b)] are different
      • √  the definitions of rape: [(6) vs. (d)] are different. (e.g., Sexual assaults, which includes rape and other types of assault, and staff rape and sexual assault are included in Washington's definition.)
      • √  Were it even possible, comparison of JCAHO's aggregate hospital data and Washington's aggregate data would be meaningless since definitions of reportable ‘events’ are different.
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