- • 1986 Medical Malpractice Policy Sets Tone
The foundation for Kansas' mandatory reporting of ‘incident reporting’ program was started in 1986 in response to a crisis in the availability of medical malpractice insurance. As part of the overall package, the Kansas Legislature enacted comprehensive risk management and patient care quality assessment laws [K.S.A. 4921 → K.S.A. 4930] that were promulgated into regulations by the Secretary of the Kansas Department of Health and Environment (KDHE), requiring hospitals and ambulatory surgical centers to establish risk management plans [K.A.R. 28-52-1] to address and manage reportable incidents within the medical facility. Medical facilities were required to submit the plan to the KDHE for approval. The legislation mandated quarterly filing with the proper licensing agency of incident reports, which included the identification of all licensed individuals involved in a reportable incident.
Additional regulations were promulgated based upon this legislation through 1998. The additional regulations [K.A.R. 28-52-2 through K.A.R. 28-52-4(a)] added structure to the incidence reporting and risk management committees, plus provided new Standard Of Care (SOC) guidelines to the regulations.
(a) "Each facility shall assure that analysis of patient care incidents complies with the definition of a “reportable incident” set forth at K.S.A. 65-4921. Each facility shall use categories to record its analysis of each incident, and those categories shall be in substantially the following form:
- (1) Standards of care met;
- (2) standards of care not met, but with no reasonable probability of causing injury;
- (3) standards of care not met, with injury occurring or reasonably probable; or
- (4) possible grounds for disciplinary action by the appropriate licensing agency."
- • Healthcare Provider Reporting Program – No Event Reporting
Per K.S.A. 65-4921(f), a "reportable incident" is defined as "an act by a health care provider which: (1) Is or may be below the applicable standard of care and has a reasonable probability of causing injury to a patient; or (2) may be grounds for disciplinary action by the appropriate licensing agency."
These incidents are those that meet SOC guidelines provided in section (a)(3) and (a)(4) above. Therefore, as stated in K.A.R. 28-52-4(b)
". . . Any incident determined by the designated risk management committee to meet category (a)(3) or (a)(4) shall be considered a “reportable incident” and reported to the appropriate licensing agency in accordance with K.S.A. 65-4923."
Hence, from the very beginning and to current day, Kansas' “reportable incident” was tied to the medical malpractice and the monitoring and identification of health professionals by licensing agencies. Public reporting of these incidents is not performed and accessability to this information is limited by the Kansas State laws governing Public Records, Documents, and Information.
- • No Adverse Event Reporting Program
Kansas does not report "adverse events." Kansas has no list of events, nor does it define any adverse events, that might qualify as ‘reportable incidents’ anywhere in statutes or regulations for any facilities. Since reportable incidents are defined only by association with the health providers, presumed ‘system’ errors within the medical facility that are not attributed to any health care provider are either not reported or do not require reporting. Kansas truly reports only providers that do not meet the K.A.R. 28-52-4 §(a)(3) and §(a)(4) Standard of Care guidelines.