May 2005

Grant Results

SUMMARY

From 2000 to 2003, staff at the National Academy for State Health Policy assisted state officials in developing strategies to reduce medical errors and improve patient safety through mandatory hospital reporting systems.

Project staff documented, analyzed and communicated information on the state's role in patient safety, state policies and reporting standards.

Part of the nonprofit Center for Health Policy Development, the academy is a nonprofit, nonpartisan organization that works on state health policy and practice.

Key Results

  • Eleven states adopted or improved mandatory reporting systems to collect standardized information about adverse events (injuries resulting from medical management).
  • The academy published one workbook, one guidebook, nine reports and seven news briefs, and developed a Web site section on Quality and Patient Safety.

Key Findings

  • A set of standardized reporting requirements that could be easily adopted might be useful at the state and national levels. (Defining Reportable Adverse Events: A Guide for States Tracking Medical Errors, March 2003)
  • States need resources to improve their systems in order to meet public expectations of a patient safety system. (How States Report Medical Errors to the Public: Issues and Barriers, October 2003)
  • Underreporting by facilities — due to concerns about medical malpractice, dislike of regulation, bad publicity, loss of market share, etc. — is a problem. (Medical Malpractice and Medical Disclosure: Balancing Facts and Fears, December 2003)
  • The project identified no relationship between mandatory reporting and an increase in malpractice claims. (Medical Malpractice and Medical Disclosure: Balancing Facts and Fears, December 2003)

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project through three grants totaling $584,222.

 See Grant Detail & Contact Information
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THE PROBLEM

Patient safety became a prominent issue after the Institute of Medicine published in 1999 a report entitled To Err is Human: Building a Safer Health Care System. The report concluded that preventable medical errors are a leading cause of death in America and laid out a comprehensive strategy by which government, health care providers, industry and consumers could reduce preventable medical errors.

One recommendation called for a nationwide, state-based mandatory reporting system to collect standardized information about adverse events (injuries resulting from medical management, not the patient's underlying condition) that result in death or serious harm, starting with reporting by hospitals. Although states can have a strong influence over the public's health, they have been fairly ineffective or scattered in their existing regulatory, information collection/reporting and purchasing functions related to quality.

Following publication of the Institute of Medicine report, state and national policy-makers began to focus attention on the role of states in reporting and reducing medical errors and improving patient safety.

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RWJF STRATEGY

Although RWJF did not have an explicit quality goal in its grantmaking mission until 2003, it has funded initiatives to improve the quality of care for people with chronic conditions. This includes several national programs:

RWJF has also funded conferences on medical errors (see Grant Results on ID#s 029013 and 034287), and research for educational programs to help reduce preventable errors during hospitalization (see Grant Results on ID# 034734).

RWJF also established a new national organization, the National Forum for Health Care Quality Measurement and Reporting (later renamed the National Quality Forum), with the goal of changing how health care quality information is collected and used in the United States. (See Grant Results on ID#s 034839, 036668 and 039645.)

In 2003, two of RWJF's four goal areas were changed to address issues related to health care quality:

  • To assure that all Americans have access to quality health care at reasonable cost.
  • To improve the quality of care and support for people with chronic health conditions.

These goals are addressed by the work of RWJF's Quality Team, which managed this project.

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THE PROJECT

Staff at the National Academy for State Health Policy assisted state officials in developing strategies to reduce medical errors and improve patient safety through mandatory hospital reporting systems for adverse events that result in death or serious harm. Part of the nonprofit Center for Health Policy Development, the academy is a nonprofit, nonpartisan organization dedicated to helping states achieve excellence in health policy and practice.

Under the first grant (ID# 038842), staff at the academy provided information to assist state officials in developing strategies to reduce medical errors and improve patient safety. Project staff:

  • Interviewed key informants (e.g., from the Joint Commission on Accreditation of Health Organizations, National Conference on State Legislatures and the National Governors' Association) to identify new or emerging state medical errors initiatives.
  • Surveyed representatives of licensure and certification agencies and public health officials in all 50 states and the District of Columbia on their activities to assess and address medical errors (via mail in February 2000).
  • Conducted in-depth telephone interviews with 16 representatives of licensure and certification agencies and hospital associations in eight states (Kansas, Ohio, Nebraska, New Jersey, Rhode Island, South Dakota, Tennessee and Texas) in May and June 2000).
  • Made site visits to state licensure and certification agencies and hospital associations, state health data agencies, consumer groups, state patient safety coalitions, state and private purchasers and health plans and health commissioners in eight states (Colorado, Florida, Kansas, Massachusetts, New York, Pennsylvania, South Carolina and Washington) from June to August 2000.

Staff produced four reports and established a Medical Errors and Adverse Events (now called Quality and Patient Safety) page on the academy's Web site. An expert medical panel guided this work (see Appendix 1).

Under the second grant (ID# 042233), staff at the academy documented, analyzed and communicated existing state policies on patient safety, focusing on reporting systems. Project staff produced six news briefs, a workbook on designing mandatory reporting systems and four reports on patient safety and mandatory reporting systems. The academy re-designed and expanded its Web site to provide state policy-makers with easy-to-use information on quality and patient safety, as well as other issues, and created a patient safety listserv.

By the fall of 2002, the nationwide, state-based mandatory reporting system for adverse events recommended by the Institute of Medicine had not been developed. Under the third grant (ID# 046686), the academy supported state activity in patient safety and worked to assure that state government and consumer groups were equal partners with hospitals in advancing system reform to improve patient safety. Project staff produced a state guide for tracking medical errors, two reports and model language for state legislation on protecting reported information. The state guide for tracking medical errors focused on the National Forum for Health Care Quality Measurement and Reporting's core set of reporting standards (27 serious preventable adverse events that should be reported; see Appendix 2). The State Alliance for Error Reporting, a team of 10 state leaders convened by the academy, compared the list of adverse events to existing state systems for tracking medical errors to identify steps needed to put the list into practice (see Appendix 3).

Academy staff convened work groups of state policy leaders and others (e.g., attorneys general, legislators and consumers) for each product to identify questions to be addressed and review the academy's work. The academy received technical assistance and guidance from the National Forum for Health Care Quality Measurement and Reporting (a private, not-for-profit organization based in Washington, which develops and implements a national strategy for health care quality measurement and reporting) and the National Conference of State Legislatures (provides research, technical assistance and opportunities for state policy-makers to exchange ideas on state issues and is based in Washington and Denver, Colo.).

Funds from The Commonwealth Fund ($135,733) and the Agency for Healthcare Research and Quality ($249,993) enabled project staff to conduct eight site visits instead of four, convene an expert medical panel to guide the first grant and expand the number of products developed.

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RESULTS

This project accomplished the following:

  • Eleven states — Connecticut, Florida, Georgia, Maine, Maryland, Minnesota, Nevada, Pennsylvania, Tennessee, Texas and Utah — adopted or improved mandatory reporting systems to collect standardized information about adverse events. Although the link between the project and states' work with mandatory reporting systems was not formally studied, RWJF and the National Academy for State Health Policy felt that the project contributed to this result. "The project contributed to the development of state roles in patient safety," said RWJF senior program officer Pamela Dickson. An RWJF senior communications officer, Paul Tarini, said "The project enriched the information environment so that states could revise things they were doing or consider new policies." "Based on the response to our reports, the number of hits on the Web site and technical assistance requests, we believe our work has been one factor that has enabled states to take on this role," said Jill Rosenthal, project director.
  • The National Academy for State Health Policy outlined minimal requirements for state mandatory reporting systems (How Safe is Your Health Care? A Workbook for States Seeking to Build Accountability and Quality Improvement Through Mandatory Reporting Systems, November 2001). See Appendix 3 for list of requirements.
  • The National Academy for State Health Policy developed a Web site section on Quality and Patient Safety. This section examines states' role in, and actions on, patient safety. It includes a toolbox (publications on medical errors, patient safety and quality; mandatory reporting laws; updates; state resources; and links to other Web sites); and a patient safety listserv for state officials. Most publications from this project are posted.
  • The National Academy for State Health Policy published one workbook, one guidebook, nine reports and seven news briefs on state activities to reduce medical errors and improve patient safety.
    • The workbook, How Safe is Your Health Care? A Workbook for States Seeking to Build Accountability and Quality Improvement Through Mandatory Reporting Systems, helps states answer essential questions in designing mandatory reporting systems and covers goals, design options, political and environmental factors and patient safety as part of an overall quality initiative.
    • The guidebook, Defining Reportable Adverse Events: A Guide for States Tracking Medical Errors, helps states create new systems, refine existing systems and compare data elements nationally. The reports provide an in-depth look at state patient safety and medication error policies and practices, including mandatory reporting, legislation, legal and policy issues, reporting to the public and medical malpractice. The news briefs are condensed versions of the reports.

Findings

The researchers published findings in many National Academy for State Health Policy publications. The key findings follow.

As reported in State Reporting of Medical Errors and Adverse Events: Results of a 50-State Survey (April 2000):

  • There was no universal use or interpretation of the terms "medical error" and "adverse event" as employed in the Institute of Medicine's report. No states had a definition of medical error. Two states use the term adverse event. Six states have a standard definition of a term that is similar to adverse event, but the term and the definition vary. Seven states do not have a standard definition of adverse event but specify which types of events must be reported.
  • Fifteen states require mandatory reporting of adverse events by hospitals, as defined by the Institute of Medicine or the state in a way that encompasses part or all of the institute's definition.
    • Although 12 states require mandatory reporting for unexpected patient deaths, there was much variability in the other types of reportable events (e.g., wrong-site surgery and medication errors).
    • Thirteen states also required reporting from ambulatory care facilities, and 12 required reporting from psychiatric hospitals.
  • Most states with mandatory reporting protect at least some reports from legal discovery, although they vary in the types of information and reports protected. Five states protect data from Freedom of Information Act requests. Seven states protect access to person-level reports. Five states promise confidentiality. Other methods of protecting data include removing certain identifying information, anonymous reporting and destroying reports after data extraction.
  • The most frequent uses of mandatory reporting data are aggregating data to identify trends (10 states), administering sanctions and assuring corrective action (nine states) and issuing public reports (eight states).

As reported in How States are Responding to Medical Errors: An Analysis of Recent State Legislative Proposals (September 2000) and The Role of State Policymakers in Patient Safety (October 2001):

  • States were exploring a variety of options to reduce preventable medical errors, including:
    • Making patient safety part of facility license requirements (Utah and California).
    • Establishing mandatory reporting systems (15 states).
    • Providing patient safety educational programs and materials for consumers and providers (Arkansas, Massachusetts and Pennsylvania).
  • The variation among the states' approaches reflects the complexities of the issue and demonstrates that there is no single road map for action.

As reported in Current State Programs Addressing Medical Errors: An Analysis of Mandatory Reporting and Other Initiatives (January 2001) (based on eight states with mandatory reporting systems):

  • State mandatory reporting requirements have been developed for a variety of purposes, not specifically to address medical errors.
  • State reporting system officials value their reporting requirements as an additional mechanism to monitor hospital quality.
  • No consistent list of adverse events or definitions exists across states, and states expressed reservations about national efforts to create uniform reporting.
  • Reporting system officials and informants perceived underreporting to be a problem. Operational barriers to compliance exist (e.g., lack of clear definitions for what to report and lack of funds to analyze activities), and hospitals fear that reporting system officials will access unprotected information.
  • State reporting system officials are developing mechanisms to validate hospital reporting and to sanction those that fail to report.
  • Mandatory reporting requirements generally focus on identifying and investigating single events and do not address system problems.
  • State reporting system officials have undertaken earnest attempts to more fully execute and improve their programs.
  • State reporting system officials had difficulty determining the costs of implementing mandatory reporting requirements, but they were nearly unanimous in declaring that insufficient resources are available to support their programs.
  • State reporting system officials take different approaches to maximizing resources for improving patient safety.
  • Individual stakeholder groups across states made similar observations about mandatory reporting requirements.
  • Mandatory reporting is one component of a multifaceted approach to reducing medical errors.
  • States generally lack a single entity with authority to address patient safety and medical errors.

As reported in Defining Reportable Adverse Events: A Guide for States Tracking Medical Errors (March 2003):

  • States are increasingly adopting reporting requirements. In 2002, state legislation was enacted to require mandatory reporting systems in Connecticut, Maine, Nevada, Pennsylvania and Tennessee. Other states introduced legislation. Nevada and Pennsylvania enacted legislation that included reporting as part of comprehensive bills to address medical malpractice crises and patient safety.
  • A set of standardized reporting requirements that could be easily adopted might be useful on the state and national levels. Such a system would prevent states that are creating new systems from reinventing the wheel and would assist states with existing systems in refining their systems and standardizing their data. It would also make data more useful by increasing opportunities for analysis.
  • State Alliance for Error Reporting members found the National Forum for Health Care Quality Measurement and Reporting's list of serious reportable events to be useful only as a starting point. They had few recommendations for modifying the list but recommended that states that are creating new systems add events to the list as needed to meet regulatory and other state requirements.
  • A process should be established for regular review and revision of the National Forum for Health Care Quality Measurement and Reporting list in light of state experience.

As reported in How States Report Medical Errors to the Public: Issues and Barriers (October 2003) (based on 21 states with mandatory reporting systems):

  • States face many challenges in their efforts to report medical errors to the public, which often pit the public's right to know against privacy concerns.
  • Seven of the 21 states with mandatory reporting systems release incident-specific data. Fourteen states issue or plan to issue aggregate reports; of these, five states do — or plan to — identify individual facilities.
  • States need resources to improve their systems in order to meet public expectations of a patient safety system. While the Institute of Medicine recommended that funds be provided to states to create reporting systems, funds are not available. Due to a lack of resources, some states have not analyzed and released data and other states have established reporting systems by law but are not operating them.

As reported in Medical Malpractice and Medical Disclosure: Balancing Facts and Fears (December 2003) (based on 19 states with mandatory reporting systems):

  • All 19 states cited underreporting as a problem, and most report that facilities often cite concerns about possible medical malpractice as a factor. Causes of underreporting may be broader and include dislike of regulation and concerns about bad publicity and loss of market share.
  • No relationship between mandatory reporting and an increase in malpractice claims was identified, regardless of whether the reported data were protected. Most states reported no indication that their system had resulted in an increase in malpractice suits.

Communications

The National Academy for State Health Policy disseminated the workbook, guidebook, reports and news briefs by mail to state officials and medical error experts and through its Web site and listserv. See the Bibliography for details on publications.

Project staff testified before Congress and briefed legislators and made presentations at annual meetings, including that of the American Medical Association State Health Legislative Meeting, National Association of Boards of Pharmacy/American Association of Colleges of Pharmacy and National Quality Forum, and to the Institute of Medicine and state committees. The academy held patient safety sessions at its annual conference.

Media outlets reported on project findings, including the American Journal of Health System Pharmacists, Baltimore Sun, Governing.com, Los Angeles Times, State Health Watch and Stateline.org.

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LESSONS LEARNED

  1. Organizations and government agencies/offices will participate in site visits if they will benefit from them. The state site visits conducted under this project were demanding for the participating states, which agreed to participate because they value National Academy for State Health Policy products. (Project Director)
  2. Outside review strengthens reports. Project staff asked work groups, the expert medical panel and site visit participants to review draft reports, which lengthened the production process but helped ensure accuracy. (Project Director)
  3. News briefs convey key information in a way that appeals to busy people. This project developed news briefs, condensed versions of reports, to convey key information to state policy-makers with limited time. (Project Director)
  4. Providing downloadable reports adds value. This project provided downloadable reports and news briefs on its Web site, which received 7,000 hits related to these products between June and September 2002. (Project Director)

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AFTER THE GRANT

States continue to enact new mandatory reporting systems and to refine existing systems, according to the Project Director. The National Academy for State Health Policy continues to serve as a resource on patient safety issues for states, the media and the health care industry through its Web site, listserv and technical assistance activities.

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GRANT DETAILS & CONTACT INFORMATION

Project

Advancing State Capacity to Reduce Medical Errors and Improve Patient Safety

Grantee

Center for Health Policy Development (Portland,  ME)

  • Literature Review and Technical Assistance for States in the Development of Strategies to Reduce Errors and Improve Patient Safety
    Amount: $ 99,758
    Dates: April 2000 to March 2001
    ID#:  038842

  • Building Understanding and State Capacity to Address Patient Safety
    Amount: $ 284,466
    Dates: June 2001 to September 2002
    ID#:  042233

  • Advancing State Regulatory Frameworks for Mandatory Reporting of Medical Errors
    Amount: $ 199,998
    Dates: December 2002 to December 2003
    ID#:  046686

Contact

Jill Rosenthal
(207) 874-6524
jrosenthal@nashp.org

Web Site

http://www.nashp.org

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Expert Medical Panel

Troyen A. Brennan, M.D., J.D., M.P.H.
Professor of Medicine
Harvard Medical School
Brigham & Women's Physicians Organization
Boston, Mass.

Karen Scott Collins, M.D., M.P.H.
Assistant Vice President
The Commonwealth Fund
New York, N.Y.

Linda Connell, R.N., M.P.
Director
NASA Aviation Safety Reporting System
Moffett Field, Calif.

Ralph Cordell, Ph.D.
Epidemiologist
Centers for Disease Control and Prevention
Atlanta, Ga.

Janet Corrigan, Ph.D., M.B.A.
Director
Board of Health Care Services
Institute of Medicine
Washington, D.C.

Marilyn Dahl
Senior Assistant Commissioner
New Jersey Department of Health & Senior Services
Trenton, N.J.

Maureen E. Dempsey, M.D.
Director
Missouri Department of Health
Jefferson City, Mo.

Pamela Dickson
Senior Program Officer
Robert Wood Johnson Foundation
Princeton, N.J.

Arnold Epstein, M.D.
Chairman
Department of Health Policy & Management
School of Public Health
Harvard University
Boston, Mass.

Frederick Heigel
Director
Department of Hospital & Primary Care Services
New York State Department of Health
Troy, N.Y.

Joseph Hilbert
Senior Health Policy Analyst
Joint Commission on Health Care
Richmond, Va.

Jan K. Malcolm
Commissioner of Health
Minnesota Department of Health
St. Paul, Minn.

Greg Meyer, M.D., M.Sc.
Director
Center for Quality Measurement and Improvement
Agency for Healthcare Research and Quality
Rockville, Md.

Robert Muscalus, D.O.
Physician General
Pennsylvania Department of Health
Harrisburg, Pa.

Donald Nielsen, M.D.
Senior Vice President
American Hospital Association
Alamo, Calif.

Stephen Schoenbaum, M.D., M.P.H.
Senior Vice President
The Commonwealth Fund
New York, N.Y.

Kathy C. Vincent, L.C.S.W.
Staff Assistant to State Health Officer
Alabama Department of Public Health
Montgomery, Ala.


Appendix 2

National Forum for Health Care Quality Measurement and Reporting's Serious Reportable Events in Health Care

The National Forum for Health Care Quality Measurement and Reporting identified 27 serious adverse events that should be reported by all licensed health care facilities in six categories: surgical, product or device, patient protection, care management, environmental and criminal acts.

Surgical Events

  • Surgery performed on the wrong body part.
  • Surgery performed on the wrong patient.
  • Wrong surgical procedure performed on a patient.
  • Retention of a foreign object in a patient after surgery or other procedure.
  • Intraoperative or immediately postoperative death in an ASA Class 1 patient (where anesthesia was administered).

Product or Device Events

  • Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the health care facility.
  • Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended.
  • Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility.

Patient Protection Events

  • Infant discharged to the wrong person.
  • Patient death or serious disability associated with patient elopement (disappearance) for more than four hours.
  • Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a health care facility.

Care Management Events

  • Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong preparation or wrong route of administration).
  • Patients death or serious disability associated with hemolytic reaction due to the administration of ABO-incompatible blood or blood products.
  • Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility.
  • Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility.
  • Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates (refers to bilirubin levels greater than 30 mg/dl; neonate refers to first 28 days of life).
  • Stage 3 or 4 ulcers acquired after admission to a health care facility.
  • Patient death or serious disability due to spinal manipulative therapy.

Environmental Events

  • Patient death or serious disability associated with an electrical shock while being cared for in a health care facility.
  • Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances.
  • Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility.
  • Patient death or serious disability associated with a fall while being cared for in a health care facility.
  • Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility.

Criminal Events

  • Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist or other licensed health care provider.
  • Abduction of a patient of any age.
  • Sexual assault on a patient within or on the grounds of a health care facility.
  • Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care facility.

The forum also identified standardized definitions of key terms.


Appendix 3

Minimum Requirements for State Mandatory Reporting Systems

The National Academy for State Health Policy offered these minimum requirements for states in its report How Safe is Your Health Care? A Workbook for States Seeking to Build Accountability and Quality Improvement Through Mandatory Reporting Systems, November 2001:

  • Mandatory reporting systems should require reporting of adverse events that result in death and serious illness.
  • Reportable events should be well defined, and states should undertake efforts to help facilities understand the reporting requirements.
  • Incident reports should include data elements necessary for holding facilities accountable (name of facility and type and date of incident).
  • Data should not be collected unless they will be used.
  • State regulatory agencies must have access to the data to meet the goal of accountability.
  • States should consider how they will ensure that corrective actions have been taken to prevent recurrence.
  • States must develop systems to store and protect confidential information.
  • States should develop policies for validating data and reviewing incident reports to determine which events require follow-up or investigation.
  • If data will be disclosed, states should consider how to present information in a format that is not misleading or punitive for reporting facilities.


Appendix 4

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

State Alliance for Error Reporting

Carol Benner
Director, Office of Health Care Quality
Maryland Department of Health and Mental Hygiene
Catonsville, Maine

Sandy Bethanis
Assistant Director, Division of Licensing and Certification
Maine Department of Human Services
Augusta, Maine

Mary (Peg) Dameron
Demonstration Project Manager
New York State Department of Health
Delmar, N.Y.

Marie Dotseth
previously Assistant to the Commissioner
Minnesota Department of Health
St. Paul, Minn.

Judy Eads
Assistant Commissioner
Bureau of Health Licensure and Regulation
Tennessee Department of Health
Nashville, Tenn.

Mary Kabriel
Risk Management Specialist and Health Facility Surveyor
Bureau of Health Facilities
Kansas Department of Health and Environment
Topeka, Kan.

Richard Lee
Deputy Secretary for Quality Assurance
Pennsylvania Department of Health
Harrisburg, Pa.

Jean Pontikas
Assistant Director, Division of Health Care Quality
Massachusetts Department of Public Health
Boston, Mass.

Frances Prestianni
Program Manager, Research and Development
New Jersey Department of Health and Senior Services
Trenton, N.J.

Don Williams
Associate Director, Health Services Regulation
Rhode Island Department of Health
Providence, R.I.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

Rosenthal J, Riley T and Booth M. State Reporting of Medical Errors and Adverse Events: Results of a 50-State Survey. Portland, Maine: National Academy for State Health Policy, April 2000.

Flowers L and Riley T. How States are Responding to Medical Errors: An Analysis of Recent State Legislative Proposals. Portland, Maine: National Academy for State Health Policy, September 2000.

The Role of State Policymakers in Patient Safety. Portland, Maine: National Academy for State Health Policy, October 2001 (News Brief).

Rosenthal J and Booth M. How Safe is Your Health Care? A Workbook for States Seeking to Build Accountability and Quality Improvement through Mandatory Reporting Systems. Portland, Maine: National Academy for State Health Policy, November 2001.

Building State Mandatory Reporting Systems for Medical Errors. Portland, Maine: National Academy for State Health Policy, November 2001 (News Brief).

Flowers L, Riley T. State-based Mandatory Reporting of Medical Errors: An Analysis of Legal and Policy Issues. Portland, Maine: National Academy for State Health Policy 2001.

Rosenthal J, Booth M, Flowers L and Riley T. Current State Programs Addressing Medical Errors: An Analysis of Mandatory Reporting and Other Initiatives. Portland, Maine: National Academy for State Health Policy, January 2001. Summary and ordering information appear online.

Rosenthal J and Riley T. Patient Safety and Medical Errors: A Road Map for State Action. Portland, Maine: National Academy for State Health Policy, 2001.

Flowers L. State Responses to the Problem of Medical Errors: An Analysis of Recent State Legislative Proposals. Portland, Maine: National Academy for State Health Policy, February 2002. Summary and ordering information appear online.

State Mandatory Reporting of Medical Errors. Portland, Maine: National Academy for State Health Policy, February 2002 (News Brief).

Building State Patient Safety Coalitions. Portland, Maine: National Academy for State Health Policy, May 2002 (News Brief).

Comden SC and Rosenthal J. Statewide Patient Safety Coalitions: A Status Report. Portland, Maine: National Academy for State Health Policy, May 2002. Also appears online.

Marchev M. The Medical Malpractice Insurance Crisis: Opportunity for State Action. Portland, Maine: National Academy for State Health Policy, July 2002. Summary and ordering information appear online.

An Act to Reduce Medical Errors and Improve Patient Health: A Case Study from Maine. Portland, Maine: National Academy for State Health Policy, August 2002 (News Brief).

The Medical Malpractice Insurance Crisis: Opportunity for State Action. Portland, Maine: National Academy for State Health Policy, September 2002 (News Brief).

Rosenthal J and Booth M. Defining Adverse Events: A Guide for States Tracking Medical Errors. Portland, Maine: National Academy for State Health Policy, March 2003. Also appears online.

Marchev M, Rosenthal J and Booth M. How States Report Medical Errors to the Public: Issues and Barriers. Portland, Maine: National Academy for State Health Policy, October 2003. Key findings and ordering information appear online.

Marchev M. Medical Malpractice and Medical Error Disclosure: Balancing Facts and Fears. Portland, Maine: National Academy for State Health Policy, December 2003. Also appears online.

How States with Mandatory Reporting Systems Report to the Public. National Academy for State Health Policy, January 2004 (News Brief).

Survey Instruments

National Academy for State Health Policy, Patient Safety and Medical Errors: Helping States Protect and Disclose Data, fielded May–June, 2003.

World Wide Web Sites

www.nashp.org. This section of the National Academy for State Health Policy's Web site on Quality and Patient Safety includes a toolbox of resources (publications on medical errors, patient safety and quality; news briefs; a list of mandatory reporting laws; updates; state resources; links to other Web sites); and a patient safety listserv for state officials. Portland, Maine: National Academy for State Health Policy.

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Report prepared by: Lori De Milto
Reviewed by: Kelsey Menehan
Reviewed by: Molly McKaughan
Program Officer: Pamela Dickson
Program Officer: Michael Rothman
Program Officer: Paul Tarini

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