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Adverse Events Report 2012

Adverse Events Report 2012

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Published by Mark Brackenbury
Adverse Events Report 2012
Adverse Events Report 2012

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Published by: Mark Brackenbury on Dec 24, 2012
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LEGISLATIVE REPORT TO THE GENERAL ASSEMBLY
Adverse Event Reporting
General Statutes of ConnecticutSection 19a-127l-nQUALITY IN HEALTH CARE PROGRAMOCTOBER 2012Jewel Mullen, MD, MPH, MPA, Commissioner
Wendy H. Furniss, RNC, MS, Chief, Healthcare Safety & Quality BranchLloyd Mueller, PhD, Supervising EpidemiologistJon C. Olson, DPM, DrPH, Epidemiologist
State of ConnecticutDepartment of Public Health410 Capitol AvenueP.O. Box 340308Hartford, Connecticut 06134-0308
 
State of ConnecticutDepartment of Public HealthLegislative Report to the General AssemblyAdverse Event ReportingQuality in Health Care ProgramTable of Contents
EXECUTIVE SUMMARY...........................................................................................................................................3BACKGROUND............................................................................................................................................................3CGS §19a-127lADVERSE EVENT DATA...........................................................................................................................................5CURRENT ACTVITIES AND FUTURE PLANS......................................................................................................8Investigation of Adverse EventsPatient Safety OrganizationsHealthcare Associated InfectionsHospital Acquired ConditionsNational and International Perspectives on Patient SafetyAPPENDICES................................................................................................................................................................15A) DEMOGRAPHIC DATA FROM REPORTS IN THE ADVERSE EVENTS DATABASE.............................17B) ADVERSE EVENT REPORTS BY TYPE AND DATE.......................................................................................18C) ADVERSE EVENT REPORTS BY FREQUENCY..............................................................................................21D) ADVERSE EVENT REPORTS AND RATES BY TYPE, ACUTE CARE HOSPITALS.................................22E) ADVERSE EVENT REPORTS AND RATES BY TYPE, CHRONIC DISEASE HOSPITALS ANDHOSPICES.....................................................................................................................................................................24F) ADVERSE EVENT REPORTS AND RATES BY TYPE,HOSPITALS FOR MENTALLY ILL PERSONS......................................................................................................25G) ADVERSE EVENT REPORTS AND RATES BY TYPE, AMBULATORY SURGICAL CENTERS,PAIN MEDICINE CENTERS, FERTILITY CENTERS, AND OUTPATIENT CHILDBIRTH CENTERS.....26H)
 
PRIMARY PAYER SOURCE BY MEDICAL FACILITY
.................................................................................
28I)
 
ADVANTAGES AND LIMITATIONS OF HARM DETECTION METHODS
.................................................
31J) REVISIONS TO NATIONAL QUALITY FORUM LIST OF SERIOUS REPORTABLE EVENTS
..............
32K) CONNECTICUT REPORTABLE ADVERSE EVENTS STARTING 2013
.....................................................
34L)
 
FACILITY COMMENTS
..................................................................................................................
52
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EXECUTIVE SUMMARY
For 2011 the number of adverse events reports (n=271) was about the same as each of the threeprior years. The most common adverse events among reports were: (1) falls resulting in seriousdisability or death, (2) perforations during open, laparoscopic, and/or endoscopic procedures, (3)stage 3-4 pressure ulcers acquired after admission to a healthcare facility, (4) patient death orserious disability as a result of surgery, and (5) retention of foreign objects in patients aftersurgery. These five categories accounted for 83% of reports for events occurring in 2011.After examining an adverse event report, which includes a Corrective Action Plan, theDepartment of Public Health (DPH) determines whether to initiate an investigation. In additionto adverse event monitoring by DPH, Patient Safety Organizations disseminate information toimprove patient care.In January 2013 Connecticut’s list of reportable events will be modified to reflect changes to theNational Quality Forum list of Serious Reportable Events, including 4 new categories.
 BACKGROUND
Connecticut General Statutes §19a-127l required the Department of Public Health (DPH) toestablish a Quality in Health Care program for health care facilities. The program is operatedthrough general DPH resources. An Advisory Committee, chaired by the DPH Commissioner ordesignee, advises the program. Mandatory adverse event
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reporting began October 1, 2002.After evaluating the program for more than a year, the Advisory Committee recommendedadoption of the National Quality Forum (NQF) list of Serious Reportable Events, plus five or sixConnecticut-specific events.Adverse events are reported to DPH by telephone and faxmachine. Reporting forms anddefinitions are located at the DPH website under “Forms.”
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After the department has decidedwhether to launch in investigation, paper-based data are entered into an electronic database.The Adverse Event reporting requirements were amended when CGS 19a-127n became effectiveJuly 1, 2004. The statute replaced the previous adverse event classification system with a list of reportable events identified by the NQF. Additionally, DPH added six Connecticut-specificadverse event definitions to supplement the NQF list, as allowed by the law. (The list appears inAppendix B.) Items on the list are of concern to both the public and healthcare professionals, areclearly identifiable and measurable, and are often preventable
.
3
 
DPH completed development of 
1
As discussed in Connecticut’s March 2004 Adverse Events report, adverse events are not the same as medicalerrors. While there is overlap between the categories, some adverse events do not result from medical errors, andsome medical errors do not result in adverse events. Adverse Events Reports are available atwww.ct.gov/dphunderStatistics & Research, then choose “Health Care Quality.”
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http://www.ct.gov/dph/cwp/view.asp?a=3115&q=390100&dphNav_GID=1601
3
More fully explained in Kenneth W. Kizer, “Clearing the Confusion about Connecticut’s New Adverse EventReporting Law,” which appears as appendix B of Connecticut’s October 2004 Adverse Events report.
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