This Procedure Outlines the Steps for Healthcare Facilities to Follow When an Adverse Event

Program: Patient Safety-Adverse Event Procedure: Procedure for Adverse Event Reporting Office: OCHS; Research, Analysis, and Data Section Effective Date: April 2009 Page: Page 1 of 2

Background: In June Chapter 70.56 RCW Adverse health events and reporting system became law. The law requires hospitals, childbirth centers, psychiatric hospitals, Department of Corrections medical facilities and ambulatory surgery facilities to report when one of the 28 adverse events occur and then to conduct a root cause analysis and forward those findings to the Department of Health.

This procedure outlines the steps for healthcare facilities to follow when an adverse event occurs.

Procedure: 1. Adverse Event Occurrence Whenever an adverse event occurs in your facility you will need to decide if the event meets the adverse event definition. Use the National Quality Forum (NQF) Serious Reportable Events in Health Care, 2002 Consensus Report, Updated October, 2006 to determine what events need to be reported. Note: Here are the directions to find the most current reference of the National Quality Forum 2006 Update. This version includes additional specifications and implementation guidance which is often helpful when deciding if an event is reportable. Follow this procedure:  Find the National Quality Forum website http://www.qualityforum.org/  Under Active Projects choose Serious Reportable Events  Under Publications and Resources choose " Serious Reportable Events Update: Access the condensed draft (Appeals Closed 11/14/08). You will find a table that includes the List of Serious Reportable Events with o Column 1: Definition o Column 2: Additional Specifications o Column 3: Implementation Guidance

2. Event Confirmation

Once you have confirmed that the adverse event is included on the NQF list you have 48 hours to notify us by:  Calling 1-888-524-6257 OR  Mailing the event description to DOH Adverse Events, P.O. Box 47853, Olympia, 98504

3. Root Cause Analysis (RCA) Conduct an RCA to determine the root causes of the event. You may utilize the procedures and methods identified by:  The Joint Commission on Accreditation of Health Care Organizations; or  The Department of Veterans Health Affairs National Center for Patient Safety; or  Another published RCA methodology with permission from the DOH Patient Safety Adverse Event Program.

Note: Acute care hospitals must include nurse staffing information in the RCA. Please see Chapter 246-320-146 WAC Adverse health events and reporting system for details Section (4) (a)(b) and (c) for details. Program: Patient Safety-Adverse Event Procedure: Procedure for Adverse Event Reporting Office: OCHS; Research, Analysis, and Data Section Effective Date: April 2009 Page: Page 2 of 2

4. Preparation of Action Plan

Create and implement a corrective action plan for each adverse event consistent with the findings of the root cause analysis. Each corrective action must include how each finding will be addressed and corrected including:  What actions will be taken to prevent each finding from reoccurring  When each correction will be completed  Who is responsible to make the corrections  How you will know that your actions are effective

5. Submission of Report/RCA and Action Plan

Send your RCA and action plan to DOH within 45 days following confirmation that an adverse event has occurred. Be sure all patient identifiers and health care staff names have been removed.

6. Review of Report/RCA and Action Plan

Once we receive your Report/RCA it will be reviewed utilizing the RCA Evaluation Scoring Tool to provide you with feedback. The entire packet that you send to us will be returned with the RCA Evaluation Tool. Often a consultation visit will be scheduled with first time facilities.

Consultation about any step in this process is always available by phone or email.

Contact: Office of Community Health Systems Linda Furkay, PhD, RN WA State Department of Health Patient Safety-Adverse Event Officer P.O. Box 47853 Research, Analysis, and Data Section Olympia, WA 98504-7853

Phone: 360-236-2875 Physical Location: email: [email protected] 243 Israel Rd SE Tumwater, WA 98501