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– Comparison of US Programs –
Overview - Part III.
ADVERSE EVENTS / Physician Reporting by States

Details and Discussion of Adverse Event (AE) Reporting States

  • •  Mandatory Adverse Event Reporting States (24 states)

    Twenty-four (24) states have mandatory, publicly-funded reporting programs, including Massachusetts, which has two mandatory adverse events reporting programs. The remaining 23 states, (except for Georgia, which has both mandatory state agency and voluntary private programs), have a single program that is administered by a State authority.

    The funding, support, and value of programs vary tremendously. Some pre-eminent State programs are well-funded and active (e.g., FL, MA, NY, PA), while others are poorly funded and lack visible public support or direction (e.g., NM, SD).

    Five states have nascent or developing programs in 2006 (e.g., IL, IN, NV, OR, WY) and lack proven track-records.

    • ◊  Facility Reporting Only (16 states)

      Sixteen (16) states have publicly-funded reporting programs that require reporting of adverse events for facilities only. Some of these State programs, as part of Medical Malpractice compromises and for other reasons, either segregate adverse event reporting from peer review or stipulate that physician providers are not routinely to be identified as part of adverse event reporting (e.g., NV, TX).

      Others within this group of States restrict adverse event reporting to facilities and either do not address or do not provide an opportunity or requirement for reporting of professional providers involved in adverse events.

      Some States address reporting of physicians under circumstances reflecting "recklessness, gross negligence or willful misconduct" (NJ) or "disciplinary actions" related to adverse events (NV), but none of these 16 states include physician names in adverse event reporting to state agencies.

    • ◊  Facility and Professional Provider Reporting (8 states)

      For the most part, physician identification as part of adverse event reporting has its roots in medical liability/malpractice legislation. Eight (8) states have mandatory, publicly-funded adverse events reporting programs that simultanously identify physicians (and sometimes other professional providers) asssociated with those events. In some states (GA, MD, RI), adverse events are reported to existing peer-review committees where physician identification is integral to disciplinary processes with transparency of this information to State agencies receiving adverse event reporting.

      In 5 other States, physicians are identified in all adverse event reports (CT, FL, MA, NY, PA) that are transmitted to State agencies, with transparency to licensure authorities, independent of whether peer review occurs with a reported adverse event. Failure to report serious adverse events triggers reporting of licencees to licensure boards in Pennsylvania.

  • •  Voluntary Adverse Event Reporting States (3 states)

    All three voluntary programs report facilities only. Because they are voluntary with no regulatory agency participation, no physician or other provider monitoring or reporting is included.

    • ◊  Privately-supported Voluntary Programs (2 states - GA, WV)

      West Virginia has a voluntary reporting program for hospitals only dating to 2001 under the sponsorship of the State's QIO, West Virginia Medical Institute. Beginning in 2004, WVMI and the West Virginia Hospital Association successfully competed for a $1.7M 3-year AHRQ grant to extend the program to Critical Access Hospitals. The program provides electronic data entry, using proprietary Quantros, Inc. software. The program has received commendation from AHRQ for its contribution to Patient Safety.

      Similarly, the Georgia Hospital Association's Partnership for Health and Accountabilitly (PHA) has provided quasi-voluntary facility reporting of adverse events since 2002. It was supported by an AHRQ Medical Error Demonstration Project grant from 2001 through 2005 and has coexisted with the Georgia regulatory authority's mandatory ‘patient incident’ reporting program since 2002.

      Neither of these State voluntary adverse event reporting programs receive State public funding, although they both have benefitted tremendously from federal grants.

    • ◊  Public/Private Collaboratively-supported Programs (1 State - OR)

      Oregon has a voluntary reporting program dating to 2003 legislation that created the Oregon Patient Safety Commission as a ‘semi-independent’ state agency. Reporting by facilities only is voluntary, and the program is mostly supported by private funding from healthcare stakeholder donations and fees imposed upon participating facilities. The pilot project ended October 2005, and the OPSC announced the beginning of full-scale operations in February 2006 [PDF]. No state General Funds contribute to the program, but annual review by the state legislature will assess the program and provide opportunities for possible future changes.

  • •  Physician Reporting Programs (2 states - KS, NE)

    Unlike those Adverse Event reporting states that identify and/or report physicians linked to adverse events, the laws of two States (KS, NE) mandate reporting of provider-professionals.

    Kansas's defines a reportable incident that facilities must report as one in which . .

    • ◊  standards of care are not met, with injury occurring or reasonably probable; or
    • ◊  there are possible grounds for disciplinary action by the appropriate licensing agency."

    A March 2003 NASHP publication [PDF] that addressed the issue of adverse event definitions across multiple states compared state definitions against the 27 NQF 'Never' Events definitions.1 Nebraska and Kansas were represented as having Adverse Event Reporting programs, with Nebraska having 24 of 27 NQF definitions and Kansas having 21 of 27 NQF definitions. The publication characterized these definitions as: "State includes this event but not explicitly."

    HOWEVER, neither Kansas nor Nebraska report adverse events. Instead, these two States require reporting of health professionals associated with serious adverse events, malpractice, or other serious behavioral problems or actions. (These latter issues are especially enumerated in Nebraska policy [PDF].) Neither State provides lists of adverse events for reporting nor do they provide a central repository for collection of adverse events. Adverse events are reported only in conjunction with reporting of professional providers.

    1  Rosenthal J and Booth M, "Defining Reportable Adverse Events: A Guide for States Tracking Medical Errors," National Academy for State Health Policy, GNL50; March 2003. [PDF]

  • •  States with NO Adverse Event Reporting (22 states)

    22 states, plus the District of Columbia have no private, public, or collaboratively funded programs for reporting of adverse events for healthcare facilities or physicians. Similarly, these States have no other programs that specifically report healthcare professionals with adverse events, even when adverse events are not reported.

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