Source: https://www.nursingtermpapers.com/quality-chasm-series-implications-nursing/
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Matched Legal Cases: ['§144', '§144', '§1279', '§1279', '§ 1279', '§ 522', '§ 144', '§ 144']

The Quality Chasm Series: Implications for Nursing - Nursing Term Papers
Reporting Serious Adverse Events and “Never Events” in Today’s Health Care System
Lawrence H. Plawecki, RN, JD, LLM; and David W. Amrhein, MD
Absent an infinitesimal percentage, most Americans seek health care services due to a legitimate health issue. Fundamental within this relationship
treat. Unfortunately, preventable medical errors do occur, and the in-
© iStockphoto.com/ Ireneusz Skorupa
nocent patient is left to suffer. In 1999, the Institute of Medicine
released To Err Is Human: Building A Safer Health System, the
culture of health care and the eradication of preventable medical errors. In the 10 years since its publication, federal and state governments and agencies
Human. This article will review what has been accomplished in this time frame.
Mr. Plawecki is Registered Nurse,
Rehabilitation Hospital of Indiana, Indianapolis, and Dr. Amrhein is Resident
Physician, Family Practice Medicine, Ball
Memorial Hospital, Muncie, Indiana.
significant financial interests in any product or class of products discussed directly
or indirectly in this activity, including
H. Plawecki, RN, JD, LLM, Registered Nurse, Rehabilitation Hospital of
Indiana, 4141 Shore Drive, Indianapolis,
’ve made a mistake.” This
simple statement, or its mere
thought, is enough to strike fear
knowledgeable of health care professionals. No matter how many
a medication administered, there is
always the likelihood of preventable error. Each year, the public
horror stories where, for example,
performed on the wrong body part,
a wrong medication administered,
care workers—their own fallibility.
Through carelessness, assumption,
overt act, or omission, the health
patient, health care providers also
JOGNonline.com
discuss the trend in today’s health
of serious adverse events or “never
events,” as well as the impact—both
impending and current—on the role
Rebuilding a Safe Health
In November 1999, the Institute of Medicine (IOM) released a
involved in the health care community. This statement, entitled To Err
System, began with a grim statistic,
estimating that between 44,000 and
98,000 people died per year from
preventable medical errors as hospital patients. The IOM (1999) report
aim or the planned action’s failure
economic terms, these errors were
country (IOM, 1999). These financial
income, lost household productivity,
care necessitated by the errors (IOM,
1999). The more specific recommendations posited by the IOM (1999)
The IOM (1999) report recommended a four-tiered approach to
to create leadership, research,
tools, and protocols to enhance the
organizations, professional groups,
As a result of these broad recommendations, state and federal
governments, agencies, and health
prevention of medical errors and,
consequently, the improved safety
IOM (1999) report, progress began
In 2001, the U.S. Congress appropriated an annual budget of $50
(Leape & Berwick, 2005). From
this appropriation, the Agency for
its improvement (Leape & Berwick,
practices to determine effectiveness,
adverse events, and creating a roadmap of evidence-based best practices
(Leape & Berwick, 2005).
by AHRQ, the National Quality Forum (NQF) (2007) created a
list of 27 serious reportable events,
Journal of Gerontological Nursing • Vol. 35, No. 11, 2009
also referred to as never events,
be divided into six separate categories, including surgical events,
product or device events, patient
protection events, care management
events, environmental events, and
criminal events (NQF, 2007). For
the purposes of this article, however,
the individual events will not be discussed, as the focus is to remain on
In 2005, the American Medical Association (AMA) released
detailing the effects of the original IOM publication. The AMA
report, while admitting there had
put into existence, discussed how
culture of safety (Leape & Berwick,
an impressive feat in today’s increasingly litigious society. Furthermore,
First, Leape and Berwick (2005)
argued that this implementation, although a substantial initial cost, will
due to the decrease in charges of adverse events and increase in efficien-
cy of staff. Second, as more methods
are implemented, newer and safer
care system and, ultimately, training of health care workers continues
to evolve and improve. Last, health
able to admit mistakes, apologize,
patients, as it has been found that
filed (Leape & Berwick, 2005).
is Human (IOM, 1999) is drawing
to a close, health care professionals can readily see and appreciate
An inexhaustive list comparing several states, their attempts to improve
patient safety, and new federal guidelines are discussed below.
In 2003, Minnesota became the
Health, 2008). Initially, this law
required Minnesota’s hospitals,
regional treatment centers, and freestanding outpatient surgical centers
reported to the public by the Minnesota Department of Health (2008)
on an annual basis. In 2005, however, an amended law took effect,
requiring Minnesota hospitals to report the occurrence of a never event
publicly, to the Minnesota Hospital
Association’s web-based Patient
Safety Registry (Dotseth, 2004).
In addition, Minnesota Statutes
§144.7065 (2005) requires applicable
event, report the underlying cause
of each event, and take corrective
such an event. Lastly, an annual report required by Minnesota Statutes
§144.7069 (2005) is published by the
thereby providing a forum for hospitals to share information and learn
from each other’s errors.
In 2004, the State of New Jersey
put into effect The Patient Safety
Act, requiring every health care
facility licensed by the New Jersey
Services (2008) to report serious
preventable adverse events. Specifically, the law required hospitals
to report these events to the New
Jersey Department of Health and
Senior Services (Patterson, 2009).
Interestingly, the law keeps hospital-specific information confidential
after its release, leaving consumers
uninformed about where the never
events actually occurred; however,
unlike other states, the law requires
immediate disclosure of medical
errors to patients who were harmed
by them (Patterson, 2009).
Also in 2004, the State of Connecticut adopted into law Public Act
No. 04-164: An Act Concerning the
Quality of Health Care, a combination of NQF and state-specific
reportable events. Originally, Connecticut only required facilities to
report injuries associated with or
caused by medical management that
resulted in measurable disability
or death, thereby allowing nonlethal and less catastrophic errors to
remain confidential from the public;
however, after review, the law was
amended to require the disclosure
of the never events as proposed
by NQF (Public Act No. 04-164,
2004). Both hospitals and outpatient
surgical facilities are required to report such events to the state Department of Public Health; however, the
disclosure of the reports is restricted
(Public Act No. 04-164, 2004).
On January 1, 2008, Illinois
became the fourth state to require
the public reporting of never events
with the implementation of the Illinois Adverse Health Care Events
Reporting Law of 2005. Initially,
this mandatory reporting law, the
Hospital Assessment Act of 2005,
required ambulatory surgical centers
and hospitals to report these events
to the Illinois Department of Public
Health (Illinois Hospital Association, 2008). In addition, it should be
noted that only the published annual
report is available publicly. Further,
any findings, corrective action plans,
and records are unavailable to the
public and are not discoverable or
admissible at law (Illinois Hospital
The State of California began the
implementation of a law, effective
in 2007, mandating that general
acute care hospitals, special hospitals, and acute psychiatric hospitals
report the occurrence of one of
their statutorily defined adverse
events to the California Department of Public Health (California
Health and Safety Code §1279.1 et
seq., 2008). Interestingly, California has two unique provisions to
its medical error reporting system.
First, reporting is required of an
event or series of events that causes
the serious disability or death
or a patient, visitor, or personnel (California Health and Safety
Code §1279.1 et seq., 2008). This
requirement is an expansion of
whom to include within the definition of adverse event. Second, the
requirements call for the patient to
be notified within 24 hours of the
discovery of the error (California
seq., 2008). This second feature creates several potential and currently
unresolved issues, including how
the patient should be informed of
the error, who should inform the
patient of such an error, and how
this information will be communicated and later analyzed by the
Of specific interest to professional nurses practicing with
geriatric patients in skilled nursing, long-term care, extended care,
assisted living, or other facilities
recognized by the individual state,
is the current incantation of the
state’s existing law. For example,
in the NQF (2007) update, only
New Jersey, Oregon, and Wyoming
appear to have laws in place that
specifically address the locations
begun shifting from that of assigning blame and determining liability
to the promotion of safety and
prevention of error. As the focus
of the practice of medicine shifts
more from diagnosis and treatment
to screening and prevention, so too
does the practice of nursing. As
this continues, nurses must always
strive to learn and implement the
most current best practices while
remaining knowledgeable of their
state’s applicable laws and federal
guidelines. The changing landscape
of nursing and health care presents
an especially difficult challenge for
those providing care to geriatric
patients who are not located in acute
The changing landscape of nursing and health care
presents an especially difficult challenge for those
providing care to geriatric patients who are not located in
most often associated with geriatric
Furthermore, on May 18, 2006,
Services (CMS) spoke for the first
time about never events. In this statement, CMS reported it was investigating ways for Medicare to reduce
or eliminate the occurrence of these
events. CMS provided its plan on
April 14, 2008, when it announced
that Medicare will cease payment for
eight specific kinds of never events.
Since releasing these statements,
CMS has extended this policy of
nonpayment from inpatient hospital
services to both service of nonfacility
providers, including physicians, and
to outpatient services. Frequent updating and research will be required
as the focus of today’s health care
dynamic and ever-changing professions in health care. In a relatively
short time, the focus of nursing has
care settings. Only by researching
the current law and forecasting state
and federal trends will nurses be
able to provide the best and safest
care for their patients while limiting
personal risk and liability. Unfortunately, errors will probably never
be eradicated, but with education
and care, nurses will be able to focus
their practice on the most important
aspect in health care—the patient.
California Health and Safety Code § 1279.1 et
seq. (2008). Retrieved from the California
Board of Nursing website: https://www.
rn.ca.gov/pdfs/regulations/npr-b-58.pdf
(2006, May 18). Eliminating serious, preventable, and costly medical errors–Never
events. Retrieved from https://www.
cms.hhs.gov/apps/media/press/release.
asp?Counter=1863
(2008, April 14). CMS proposes to expand
quality program for hospital inpatient services in FY 2009. Retrieved from https://
www.cms.hhs.gov/apps/media/press/
release.asp?Counter=3041
Connecticut Public Act No. 04-164: An act
concerning the quality of health care
(2004). Retrieved from https://www.
cga.ct.gov/2004/act/Pa/2004PA-00164R00SB-00566-PA.htm
Dotseth, M. (2004). The reporting of adverse
events in health care: Minnesota’s law. Retrieved from the Minnesota Department of
Health website: https://www.health.state.
mn.us/patientsafety/ae/lawoverview.pdf
Illinois Adverse Health Care Events Reporting Law of 2005, 410 I.L.C.S. § 522.
Retrieved from https://www.ilga.gov/
legislation/ilcs/ilcs5.asp?ActID=2715&C
hapAct=410%C2%A0ILCS%C2%A052
2%2F&ChapterID=35&ChapterName=
P U B L I C + H E A LT H & A c t N a m e
=Illinois+Adverse+Health+Care+
Events+Reporting+Law+of+2005%2E
Illinois Hospital Association. (2008, August).
Summary of the Illinois adverse health
event reporting law of 2005. Retrieved from
http://www.ihatoday.org/issues/safety/
errorrepsumm.pdf
Institute of Medicine. (1999). To err is human: Building a safer health system. Retrieved from the National Academies Press
http://www.nap.edu/catalog.
php?record_id=9728
Leape, L.L., & Berwick, D.M. (2005). Five
years after To Err is Human: What have we
learned? Journal of the American Medical
Association, 293, 2384-2390.
Minnesota Department of Health. (2008,
September 19). Patient safety. Retrieved from https://www.health.state.
mn.us/patientsafety/index.html
Minnesota Department of Health. (2009,
April 20). Background on Minnesota’s
Adverse Health Events Reporting Law.
Retrieved from https://www.health.state.
mn.us/patientsafety/ae/background.html
Minnesota Statutes § 144.7065: Facility requirements to report, analyze, and correct (2005). Retrieved from https://ros.
leg.mn/bin/getpub.php?pubtype=STAT_
CHAP_SEC&year=current&
section=144.7065&image.x=11&image.
y=9&image=Get+Section
Minnesota Statutes § 144.7069: Interstate coordination: Reports (2005). https://www.
revisor.leg.state.mn.us/data/revisor/
statutes/2005/144/7069.html
National Quality Forum. (2007). Serious reportable events in healthcare 2006 update:
A consensus report. Retrieved from https://
www.qualityforum.org/WorkArea/linkit.
aspx?LinkIdentifier=id&ItemID=1249
Services. (2008, March). Mandatory patient
safety reporting requirements for licensed
health care facilities (revised)–Patient
safety initiative. Health care quality assessment. Retrieved from https://www.nj.gov/
health/ps/documents/final_directions_
Patterson, M.J. (2009, April 1). Lifting the
veil on medical horrors: New Jersey bill
would require reporting of “never” events.
Retrieved from the AARP Bulletin Today
website: https://bulletin.aarp.org/states/nj/
articles/public_disclosure.html