Health facility mandates

1.Who must report incidents at the institution?
2.Discuss whether there is a difference in the types of incidents that must be reported and
explain those differences or similarities.
3.Who investigates the incidents at the hospital level?
4.Explain any steps taken to protect incident reports and control who may obtain the
5.Explain if and how a root cause analysis is utilized.
Part II: Discuss whether a voluntary or mandatory incident reporting effort is best. List
the pros and cons of each kind of system.

522 Module 2 SLP: Adverse incident reporting

Question 1
According to Utah Department R380-200, each health facility is mandated to report to the
department of health about the 72 hours after patient safety incident have occurred. These
includes events such surgical procedures that have been performed on wrong body part or
patient, incorrect surgery procedures, neonatal hyperbilirubinemina (<25 milligrams/ per
deciliter), hospital acquired illness, patient harassment or disappearance of patient with cognitive
impairments that have lasted for more than 4 hours. The facility report should include patient
information, situation, and facility information, type of occurrence, analysis and corrective
actions (The Utah Administrative Code (Rule R380-200), 2014).
Utah department of health adverse reporting law is similar to the Minnesota ‘Adverse
Health Events Reporting Law’, in that the healthcare facility must report adverse effects that

522 Module 2 SLP: Adverse incident reporting

have occurred in the healthcare facility within 15 days after the incidence has occurred. The law
further recommends that it is important to convene a quality team to conduct root cause analysis
to investigate the factors that led to the adverse effects. The RCA teams are expected to submit
their findings and corrective action plan (Minnesota Department of Health Web site, 2014).
Question 2
According to Utah Department of health, the following incidents are categorized into 3
categories including a) reportable adverse events whose consequences is assessed by harm scale,
b) adverse events that result in patient harm or death and c) adverse events as referenced by
reporting rules (The Utah Administrative Code ( Rule R380-200), 2014). In general the Utah
Department of Health and Minnesota Department of Health adverse events includes surgical
procedures performed on wrong body part, wrong patient, incorrect surgical procedures,
retention of foreign surgical objects on patients body, neonatal hyperbilirubinemia, discharging
infants to a wrong person, abduction of patient, fire, medication errors, use of contaminated
drugs, hemolytic reaction and embolism after surgical procedure, radiology to wrong body part,
prolonged fluoroscopy, and hospital acquired illnesses such as patient falls and pressure ulcers.
However, the Minnesota Department of Health has additional adverse effects to include criminal
adverse events caused through care delivered by someone impersonating nurse, pharmacists,
physician, nurse pharmacists or other licensed providers ((The Utah Administrative Code ( Rule
R380-200), 2014; Minnesota Department of Health Web site, 2014).
Question 3
Both Utah Department of Health and Minnesota Department of Health, the risk
management teams are responsible for the investigations at hospital levels. The facility
designates a leader to lead the investigation and to conduct a root cause analysis. During the

522 Module 2 SLP: Adverse incident reporting

review, risk cause factors are identified; solutions to these issues are identified to ensure that
reasonable system changes are made to correct the incident, ad to prevent similar incidents from
occurring. The investigations primarily focus on the system processes (not individual
performance) and to identify changes that will lead to reforms or development of new systems so
as to prevent these events from re-occurring (The Utah Administrative Code ( Rule R380-200),
Question 4
In both department of health, there are steps outlined to control who might obtain the
incident reports information. The Utah Department of Health guidelines R380-200-6 highlights
the approaches to protect confidentiality of information which states that the incident reports
information should not be released to any pursuant (subsections 26-3-7 (1), because the
information produced is highly confidential and privileged under the Title 26, Chap. 25. On the
other hand, the Minnesota Department of health promotes sharing of information between the
facilities through “data sharing Minnesota Hospital Association” so that the facilities can learn
from each other experiences (Minnesota Department of Health Web site, 2014).
Question 5
Root cause analysis is utilized during cause analysis of adverse patient’s incidences. RCA
is an error analysis tool, used to identify underlying problems that increase likelihood of adverse
incidents by avoiding the common trap of focusing individual’s mistakes. This tool uses system
approach to figure out active errors (those that occur at the interface between the complex system
and human) and the latent errors (hidden issues within the healthcare system that contribute to
adverse events. The RCA tool follows a pre-specified protocol that starts with data collection,
holistic analysis of the data collected through reconstructions of the events through observation,

522 Module 2 SLP: Adverse incident reporting

staff interviews and record review. The sequence of events that led to the adverse outcome are
analyzed with the aim of identifying ways the event occurred, why they occurred, and the
specific interventions to prevent future harm from happening by eliminating active and latent
errors (Root Cause Analysis, 2012).

PART II: Voluntary vs. Mandatory reporting systems

Voluntary patient safety reporting systems are important because they help in detecting
safety problems and quality issues. The initial reports are obtained from the frontline personnel
involved in the actions. This type of reporting is a passive form of surveillance from unsafe
situations or near misses (Howell et al., 2015). The benefits of voluntary reporting systems are
that it increases acceptability and involvement of the frontline healthcare staff. In addition, the
people who have been involved in the incidents makes the report, which highlights that the staffs
have legitimate concerns regarding quality performance concerns. In most incidences, voluntary
reporting systems are confidential which indicates that any person who witnessed the incidence
can make the report because there is legal protection unless the incident occurred due to
professional misconduct. However, voluntary reporting system is associated with limitations
such as selection in reporting bias and may capture only a fraction of the incident especially if
there are conflicts of interest (Voluntary Patient Safety Event Reporting (Incident Reporting),
In some States, reporting of adverse events is mandatory. The benefits of adverse
reporting are that it acts as a direct acknowledgement of the adverse event. It helps in detecting
adverse incidents that would go unnoticed by the relevant governing bodies. This kind of
reporting is important because it reinforces moral obligation of every person to protect the

522 Module 2 SLP: Adverse incident reporting

patient from harm and abuse. The challenges of mandatory reporting are that it is usually
governed by the States department of health, increasing the risk of underreporting to avoid
punitive actions, legal penalties and public scrutiny. This implies that some staff will be reluctant
to report errors due to external mandatory programs but will report internally. The health systems
may make it challenging for staff to report the adverse incidents that have ‘hand down
punishments.’ This is because the organization’s first priority is to minimize organizations
exposure to public distrust and increased liability. This generally implies that the situation is
prone to hindsight bias (Pham, Girard, & Pronovost, 2013).

522 Module 2 SLP: Adverse incident reporting


Howell, A.M., Burns, E.M., Bouras, G., Donald, L.J., Athanasiou, T., Darzi,A. (2015). Can
patient safety incident reports be used to compare hospital safety? Results from a
quantitative analysis of the English National Reporting and Learning System data. PloS
one 10(12):e0144107.
Minnesota Department of Health Web site (2014). Patient Safety. Retrieved
Pham, J. C., Girard, T., & Pronovost, P. J. (2013). What to do With Healthcare Incident
Reporting Systems. Journal of Public Health Research, 2(3), e27.

Root Cause Analysis. (2012). Agency for Healthcare Research and Quality.
The Utah Administrative Code ( Rule R380-200). (2014). Patient Safety Sentinel Event
Reporting. Patient Safety Initiatives. Utah Department of Health Web site.
Voluntary Patient Safety Event Reporting (Incident Reporting) (n.d.). U.S. Department of Health
and Human Services, Agency for Healthcare Research and Quality; Patient Safety