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Medical Errors and Patient Safety


The Commonwealth of Virginia, via legislative activity that began in 2000, made a very deliberate and well-researched review of patient safety and adverse event reporting options and decided not to establish an adverse event reporting program. Virginia has limited mandatory reporting that is managed via Virginia Health Information (VHI), a not-for-profit health data organization authorized by the Virginia legislature. However, this reporting falls short of a reporting program.

  • •  2000 Joint Commission on Health Care Study

    The Virginia Joint Commission on Health Care (JCHC) is a legislative commission created by the 1992 General Assembly. The purpose of the JCHC is to study, report, and make recommendations on all areas of health care.

    In response to a legislative request shortly after publication of the IOM's To Err is Human, the House of Representatives in early 2000 passed House Joint Resolution 9 (HJ9). Although lacking approval by the Assembly, HJR9 directed the JCHC (via a letter and authority of the Rules Committee of the House) to perform a study of Virginia to:

    • √  examine current Virginia and national data regarding adverse medical events,
    • √  review current patient safety initiatives in Virginia, and
    • √  develop specific recommendations for implementation of patient safety measures in Virginia.
    • ◊  Virginia Considers Options

      In June 2000, the JCHC returned a presentation to the legislature, Review of Patient Safety and Medical Errors in Virginia [PDF], and an accompanying issue brief [PDF]. The report included a 10-year strategy for health care quality in Virginia that included eleven distinct policy options. A summary of legislative options for Patient Safety (PS) and Medical adverse event (AE) / medical error reporting (MER) included:

Option Description of Policy Options
Do Nothing
Identify and analyze AE / MER with existing Virginia Patient Level Data System (facility administrative data)
Expand "e-codes" reporting via ICD-9 CM hospital administrative databases
DOH / health care providers collaboration to encourage and, if necessary, regulate PS and MER reduction, assuming standards are defined.
State-administered voluntary AE / MER reporting.
Require professional education programs for PS via State licensing authority
CME requirements for professionals' PS education
Publish extensive ‘Physician Profiles’ and establish whistleblower protections
Incorporate PS and MER standards into provider contract provisions of State and Medicaid health plans
Incorporate PS & MER into Quality improvement requirements for managed care health insurance licensees
Develop PS strategies in outpatient and physician office settings under guidance of Virginia academic institutions

    • The JCHC subsequently published a Summary of Public Comments [PDF] in response to this report. Among the 19 organizational and individual respondents to this report was Virginians Improving Patient Care and Safety (VIPC&S), a very influential statewide patient safety coalition with broad participation of membership including 25 separate health care provider organizations.

      All respondents repudiated the "Do Nothing" option. None of the respondents strongly favored one option above all others. The Virginia Trial Lawyer Association disapproved of all options, stating that none of them addressed physician ‘accountability.’

      Response to Option V (voluntary reporting) was not favored by respondents, pending consideration of other options that included Option II. Option II included exploration of “. . the feasibility and potential benefit of using the Virginia Patient Level Database to help identify and analyze the occurrence of adverse medical events and medical errors.” The VIPC&S and other respondents recommended further investigation of this option. Lukewarm support from the respondents was provided for Option III , which would have extended “e-code” reporting, as occurs in New York and Tennessee and as recommended by the National Association of Health Data Organizations (NAHDO).

      A policy option for a mandatory event reporting program, as recommended by the IOM report, was not included in this review, although Option IV opened the door to regulation "if necessary," and after collaborative efforts to "encourage" patient safety and error reduction.

      Option II hinged on the fact that “external cause of injury,” must be reported by health facilities as one of 15 data elements in the form of ‘e-codes’ [VA Code § 32.1-276.6(B)(11)]. In compliance with this reporting requirement, hospitals submit the ICD-9 codes that correspond to specific types of events related to the provision of medical care. These data are reported to Virginia Health Information (VHI) into the Virginia Patient Level Data System (VPLDS) by hospitals for their in-patients. Among the types of data submitted are included:

      • •  Misadventures to patients during surgical and medical care,
      • •  Drugs, medicinal and biologic substances causing adverse effects in therapeutic use, and
      • •  Surgical and medical procedures as the cause of abnormal reaction of patient or later complication.

      The list of events that might be generated from this single report requirement clearly represents a potentially large but finite number of e-code events, exemplified by the 54 adverse events in New York's NYPORTS program and the 48 adverse events in Tennessee's reporting program. The JCHC 2000 review of patient safety presentation to the legislature [PDF, p13-17, 25-27] reported aggregate facility information for Virginia data on these hospital events.

    • ◊  None of Reporting Options Adopted

      Despite statutory authority for reporting of e-code “external cause of injury,” (Option II) which includes some adverse adverse events or medical errors [VA Code § 32.1-276.6(B)(11)], Virginia has elected not to report them in any subsequent reports. No subsequent action since the 2000 JCHC brief on Patient Safety and Medical errors has pursued Option II, and there is no evidence of publication or feedback to facilities for events reported as “external cause of injury” in the VHI Patient Level Data System database.

      Therefore, Virginia continues with mandatory reporting of events, but it has NO event reporting program.

      A likely similar pattern of non-use of ‘e-codes’ exists in other states, too. In fact,

      "According to an American Public Health Association report, 42 states and the District of Columbia have statewide hospital discharge data systems in place: 36 of these routinely collect some level of E-codes. 23 of the 36 states have mandated E-coding; however, due to pressure from hospitals that sought to avoid a mandate on some codes, some states specifically exclude from the E-code requirement the categories of codes (E870-E879) that are most relevant to the tracking of adverst events and medical errors." [Rosenthal J and Riley T, Patient Safety and Medical Errors: A Road Map for State Action, NASHP (2001), GNL37 [pdf] 1 See NAHDO information on e-codes [PDF].

      1   The original reference for this article is: Annest JL, Conn JM, McLoughlin E, Fingerhut LA, Pickett D, Gallagher S. How states are collecting and using cause of injury data. San Francisco, California: Trauma Foundation at San Francisco General Hospital, 1998

  • •  2002 - Virginia Promotes Patient Safety Organizations

    In 2002, the Virginia assembly passed legislation that amended VA Code §§ 8.01-581.16 and 8.01-581.17 of the medical malpractice Code of Virginia. This statute defined Patient Safety Organizations as independent organizations and provided immunities to participants of Patient Safety Organizations from civil action and provided protections of confidentiality and discovery for all patient safety data and activities. Voluntary reporting of hospitals to the ‘Sentinel Event’ reporting program of JCAHO was clearly favored by this law; JCAHO promoted the law as introduced. Another feature of this law addressed whistleblower protection for informants by prohibiting retaliation by employers against reporting employees [VA Code § 8.01-581.17(h)]. This feature of the law was part of Option VIII mentioned in the 2000 JCHC policy brief.

  • •  2002 - Virginia Health Information (VHI)

    As mentioned above, Virginia Health Information (VHI) is a not-for-profit health data organization authorized by the Virginia legislature in 1996, and all Health Care Data Reporting in Virginia is provided to VHI (... more info). VHI collects and collates all Virginia Patient Level Data in implementations of ‘e-codes’ utilized in JCHC Health Policy Options II and III.

    The cardiac care mortality information reflects the sole category of healthcare data that is disseminated as procedure-related performance measures by Virginia. These cardiac performance measures are distributed in both aggregate and hospital-identified formats. Whereas all transmitted VPLDS data transmitted to VHI includes individual physician identifiers, physicians have not yet been included in these cardiac reports.

  • •  2006 - Virginia Commission on Health Reform

    Virginia Governor Tim Kaine (D) announced the creation of a Commission on Health Reform on July 20, 2006. Executive Order No. 31 [PDF] calls for:

    "identifying and implementing national best practices in health care at the state level in terms of access to care, improving quality and safety of care, providing long-term care, and addressing affordability of care."

    In addition, the Governor called for

    "Working closely with the Joint Commission on Health Care and fostering executive – legislative cooperation on health care issues."

    The Commission will return with a report on September 1, 2007.

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