Legal Incident Reporting Requirements

Module 3 – SLP
Legal Incident Reporting Requirements
As your second assignment toward completion of the Session Long Project, you will need to
research voluntary versus mandatory incident reporting systems.
Part I: Review the Utah and Minnesota Incident reporting mandates. Compare these
Who must report incidents at the institution?
Discuss whether there is a difference in the types of incidents that must be reported and
explain those differences or similarities.
Who investigates the incidents at the hospital level?
Explain any steps taken to protect incident reports and control who may obtain the
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
SLP Assignment Expectations
Limit your response to 4 pages, not including title and reference pages.
Be sure to utilize at least 3-4 scholarly references to support your discussions.
Be sure to properly cite your references within the text of your assignment and listed at the
Be sure to apply critical thinking skills to the write-up of your assignment, especially in
regard to #2 above.

Legal Incident Reporting Requirements

Part I

  1. Who should report incidents at the institution
    In Minnesota, the boards which license podiatrists, pharmacists, nurses, physician assistants, and
    physicians are charged with reporting to MDH events that are brought to their attention that may

qualify as adverse health care events. Minnesota hospitals and outpatient surgical centers are also
mandated to report any occurrence of the reportable advance events within 15 days (Minnesota
Department of Health, 2009). Under the Utah Administrative Code, the facilities mandated to
report adverse health events include orthopedic hospitals, long-term acute care hospitals,
substance abuse hospitals, rehabilitation hospitals, psychiatric hospitals, ambulatory surgical
centers, critical access hospitals, and general acute hospitals. The Utah law provides that, in case
of a transfer, a facility which reasonably suspects the occurrence of an adverse health event
should report the suspected event to the facility that initiated the transfer. The report should
consist of facility information, patient information, event information, analysis, and corrective

  1. Whether there is a difference in the types of incidents that must be reported and
    explain those difference or similarities
    Both Minnesota and Utah laws classify reportable health events into surgical events, product or
    device, patient protection, care management, environmental events, and criminal events. The
    adverse health events are classified in such a way as to make it easier for the facilities to
    investigate the events and come up with a corrective action that aims at reducing future risks of
    the same kind (Utah Department of Administrative Services, 2014).
  2. Who investigates the incidents at the hospital level?
    Under Minnesota’s law, MDH is still charged with the responsibility of investigating complaint
    and enforcing certification and licensing requirements for certain health care facilities. MDH
    generally reviews adverse heath events submitted in accordance with the Adverse Health Events
    Reporting Law in line with prescribed procedures. In cases where MDH discovers an event that

has not been submitted within the limit of time required under the statute, the facility should be
subjected to investigation by MDH in line with the Maltreatment of Minors Act or the
Vulnerable Adult Act. Where MDH receives a complaint concerning a prospective incident, the
hospital may be investigated, whether or not the report was made through the adverse health
events reporting system.
The Utah law provides that a facility should designate a responsible individual to lead in the
investigation of adverse health events. Within 60 days of determination of the adverse health
event, the incident facility submits a report with an action plan to the Utah Department of
Administrative Services (‘the Department’) and the facility’s administration in a Department-
approved paper or electronic format that contains the type of harm, contributing factors, and
actions taken.

  1. Steps taken to protect incident reports and control who may obtain the information
    In Minnesota, the mandated facilities are supposed to report the incidents into a secure,
    password-protected, web-based registry. The Utah law mandates the Department to hold adverse
    health event reports confidentially due to the needs of public interest to promote health care
    systems improvements. The Department is required to exercise discretion and not to release the
    data collected to any person. In addition, the Utah law mandates the facilities to keep the
    information collected or produced confidential and privileged.
  2. The utilization of a root cause analysis
    In Minnesota, the facility is supposed to select an internal team to carry out a ‘root cause
    analysis’ that involves inspecting the role of different factors that might have resulted into the
    event such as organizational culture, training, equipment, staffing, and communication. Within

60 days, the team submits its findings and corrective action plans. A clinical and quality
improvement team reviews each event to make sure that the root cause analysis and corrective
action plan meet all standards, and that the facility is taking necessary steps toward the reduction
of the risk. The facility obtains feedback from the review team, and submits responses and
alterations to their plan until review criteria are fulfilled.
Under Utah law, the facility is required to develop a root cause analysis process and assign a
responsible person to lead the facility in each adverse health event. The Department
representative may participate in the root cause analysis in a consultative state to enhance the
credibility and diligence of the root cause analysis. The Department representative notifies the
facility lead within seventy-two hours of receiving the report of the adverse health event if it
intends to get involved in the facility’s root cause analysis. The representative is not supposed to
participate in the root cause analysis meeting unless invited by the facility lead.
Part II: Whether a voluntary or mandatory incident reporting effort is best
Voluntary incident reporting involves reports made without any administrative or legal
requirements to do so (Wu, Pronovost & Morlock, 2002). On the other hand, mandatory incident
reporting involves the reporting of incidents in accordance with administrative or legal
requirements. Mandatory reporting is the best because an individual is compelled by law or the
administration to report. Voluntary reports are not reliable because an individual is not under any
obligation to report and he may choose not to report the incident. Voluntary reporting is only
effective in cases where incentives are available. However, mandatory incident reporting attracts
penalties for mandated persons who fail to report incidents. The disadvantage with mandatory

incident reporting is that it may not be all-inclusive and some incidents may not be covered
under the legal or administrative scope of the events to be reported (Wald & Shojania, 2001).


Minnesota Department of Health. (2009). Background on Minnesota’s Adverse Health Events
Reporting Law.

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