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Improving Patient Safety Through Adverse Event Reporting Kathy Schmitt, MPA Research Analysis and Data Section Manager Office of Community Health Systems.

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Presentation on theme: "Improving Patient Safety Through Adverse Event Reporting Kathy Schmitt, MPA Research Analysis and Data Section Manager Office of Community Health Systems."— Presentation transcript:

1 Improving Patient Safety Through Adverse Event Reporting Kathy Schmitt, MPA Research Analysis and Data Section Manager Office of Community Health Systems Washington State Department of Health

2 Improving Patient Safety Through Adverse Event Reporting Health care system is large, complex, fragmented Adverse Events are typically preventable medical errors that result in patient death or serious disability Adverse Event Reporting Systems Promote quality improvement in facilities Enhance open and honest conversations Support learning, sharing information, and identifying best practices

3 Improving Patient Safety Through Adverse Event Reporting Washington State Adverse Event Reporting System Law established in 2006 NQF – List of 29 adverse events Hospitals, Psychiatric Hospitals, Child Birth Centers, Department of Corrections Medical Facilities, and Ambulatory Surgery Facilities are required to report adverse events to DOH Quality Improvement Focus

4 Improving Patient Safety Through Adverse Event Reporting Reporting an Adverse Event Notify DOH within 48 hours of confirmation of event Electronic reporting form Paper reporting form – fax, , mail Toll free hot line Complete a Root Cause Analysis and send to DOH within 45 days Quarterly Check-in Survey

5 Notification of Adverse Events Total of 1,360 events reported from June 2006 to June – Pressure Ulcers 370 – Surgical Events 233 – Falls 37 – Criminal Events 29 – Medication Errors 62 – Other Event Types Improving Patient Safety Through Adverse Event Reporting

6 Changes in DOH Adverse Event Program Budget impacts WAC changes, effective 10/1/2012 Revised web-page Electronic notification form Compile and share findings from RCA’s

7 Improving Patient Safety Through Adverse Event Reporting List of Adverse Events NQF Guidance Adverse Events webpage

8 Thank You! Kathy Schmitt, MPA


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