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Improved Patient Safety

State Reporting: Issues & Activities

Presenters:

Fred Heigel, Director, New York State Department of Health.

Scott Williams, M.D., Deputy Director, Utah Department of Health.


Approximately 20 States have established systems for reporting medical errors. Some of these reporting systems are voluntary in nature; others require the reporting of certain medical errors to the State. Critical to improving patient safety in health care settings, these systems also provide a mechanism that allows facilities to generate a database to track and compare trends over a period of time.

Two different State reporting systems were discussed in some detail at the workshop:

  • The New York Patient Occurrence Reporting and Tracking System (NYPORTS) is a mandatory adverse event reporting system that collects information on 54 reportable occurrence categories.

    As described by Fred Heigel of the New York Department of Health, the goal of the system is to improve quality and patient safety within New York's hospitals. The information collected is protected against public disclosure and is analyzed by the State at the individual facility level, across networks, and can be combined to provide State-level data. Findings are shared with individual hospitals and networks for quality improvement purposes. In addition, the State also publishes news and alerts and quarterly and annual reports that provide statewide information and share quality improvement lessons learned.

  • The Utah Department of Health (DOH) used an administrative rule in the DOH statutory authority to establish a reporting system that uses data already collected to focus on sentinel adverse events and adverse drug reactions.

    Dr. Scott Williams described how Utah data from Death Certificate Y Codes for Complications is used to identify problems and develop a variety of action plans including, but not limited to, staff and physician education, new or revised procedures or policies, and improved communication among health care teams. Adverse drug events (ADEs) using ICD-9-CM codes are also analyzed to reduce medication errors.


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