§ 23-17-40 - Hospital events reporting.
SECTION 23-17-40
§ 23-17-40 Hospital events reporting.– (a) Reportable events as defined in subsection (b) shall be reported to thedepartment of health division of facilities regulation on a telephone numbermaintained for that purpose. Hospitals shall report incidents as defined insubsection (b) within twenty-four (24) hours of when the accident occurred orif later, within twenty-four (24) hours of receipt of information causing thehospital to believe that a reportable event has occurred.
(b) Reportable events are defined as follows:
(i) Fires or internal disasters in the facility which disruptthe provisions of patient care services or cause harm to patients or personnel;
(ii) Poisoning involving patients of the facility;
(iii) Infection outbreaks as defined by the department inregulation;
(iv) Kidnapping and inpatient psychiatric elopements andelopements by minors;
(v) Strikes by personnel;
(vi) Disasters or other emergency situations external to thehospital environment which adversely affect facility operations; and
(vii) Unscheduled termination of any services vital to thecontinued safe operation of the facility or to the health and safety of itspatients and personnel.
(2) Any hospital filing a report with the attorney general'soffice concerning abuse, neglect and mistreatment of patients as defined inchapter 17.8 of this title shall forward a copy of the report to the departmentof health. In addition, a copy of all hospital notifications and reports madein compliance with the federal Safe Medical Devices Act of 1990, 21 U.S.C.§ 301 et seq., shall be forwarded to the department of health within thetime specified in the federal law.
(c) Any reportable incident in a hospital that results inpatient injury as defined in subsection (d) shall be reported to the departmentof health with seventy-two (72) hours or when the hospital has reasonable causeto believe that an incident as defined in subsection (d) has occurred. Thedepartment of health shall promulgate rules and regulations to include theprocess whereby health care professionals with knowledge of an incident shallreport it to the hospital, requirements for the hospital to conduct a rootcause analysis of the incident or other appropriate process for incidentinvestigation and to develop and file a performance improvement plan, andadditional incidents to be reported that are in addition to those listed insubsection (d). In its reports, no personal identifiers shall be included. Thehospital shall require the appropriate committee within the hospital to carryout a peer review process to determine whether the incident was within thenormal range of outcomes, given the patient's condition. The hospital shallnotify the department of the outcome of the internal review, and if thefindings determine that the incident was within the normal range of patientoutcomes no further action is required. If the findings conclude that theincident was not within the normal range of patient outcomes, the hospitalshall conduct a root cause analysis or other appropriate process for incidentinvestigation to identify causal factors that may have lead to the incident anddevelop a performance improvement plan to prevent similar incidents fromoccurring in the future. The hospital shall also provide to the department ofhealth the following information:
(1) An explanation of the circumstances surrounding theincident;
(2) An updated assessment of the effect of the incident onthe patient;
(3) A summary of current patient status including follow-upcare provided and post-incident diagnosis; and
(4) A summary of all actions taken to correct identifiedproblems to prevent recurrence of the incident and/or to improve overallpatient care and to comply with other requirements of this section.
(d) Incidents to be reported are those causing or involving:
(1) Brain injury;
(2) Mental impairment;
(3) Paraplegia;
(4) Quadriplegia;
(5) Any type of paralysis;
(6) Loss of use of limb or organ;
(7) Hospital stay extended due to serious or unforeseencomplications;
(8) Birth injury;
(9) Impairment of sight or hearing;
(10) Surgery on the wrong patient;
(11) Subjecting a patient to a procedure other than thatordered or intended by the patient's attending physician;
(12) Any other incident that is reported to their malpracticeinsurance carrier or self-insurance program;
(13) Suicide of a patient during treatment or within five (5)days of discharge from an inpatient or outpatient unit (if known);
(14) Blood transfusion error; and
(15) Any serious or unforeseen complication, that is notexpected or probable, resulting in an extended hospital stay or death of thepatient.
(e) This section does not replace other reporting required bythis chapter.
(f) Nothing in this section shall prohibit the departmentfrom investigating any event or incident.
(g) All reports to the department under this section shall besubject to the provisions of § 23-17-15. In addition, all reports underthis section, together with the peer review records and proceedings related toevents and incidents so reported and the participants in the proceedings shallbe deemed entitled to all the privileges and immunities for peer review recordsset forth in § 23-17-25.
(h) The department shall issue an annual report by March 31each year providing aggregate summary information on the events and incidentsreported by hospitals as required by this chapter. A copy of the report shallbe forwarded to the governor, the speaker of the house, the senate presidentand members of the health care quality steering committee established pursuantto § 23-17.17-6.
(i) The director shall review the list of incidents to bereported in subsection (d) above at least biennially to ascertain whether anyadditions, deletions or modifications to the list are necessary. In conductingthe review, the director shall take into account those adverse eventsidentified on the National Quality Forum's List of Serious Reportable Events.In the event the director determines that incidents should be added, deleted ormodified, the director shall make such recommendations for changes to thelegislature.