Mod 3 SLP
Patient safety remains a top priority in the healthcare system. The ubiquitous nature of patient safety systems developed at hospitals does not guarantee solid protection against the most common safety hazards. Incident reporting mandates obligate healthcare facilities to report sentinel events timely and develop systemic measures to avoid similar errors in the future. Voluntary and mandatory incident reporting systems provide favorable conditions for the regular surveillance of urgent and latent patient safety issues, but the former system raises doubts concerning its effectiveness to successfully accomplish the intended patient safety mission.
Incident reporting encompasses a diverse set of measures, processes, and requirements. Each stage of the system runs a unique incident-reporting mandate. State incident reporting systems display considerable similarities. The examples of Utah and Minnesota incident reporting mandates uncover the most common principles of incident reporting utilized by the states. Both states require all facilities to report adverse health events to the commissioner as soon as possible (The Office of the Revisor of Statutes, 2014; Utah Department of Administrative Services, 2013). In Minnesota, such responsible facilities include outpatient surgical centers and hospitals (Minnesota Statutes, 2014). In Utah, the term facility covers the following entities: general acute and critical access hospitals, psychiatric hospitals, general ambulatory centers, rehabilitation and orthopedic hospitals, substance abuse facilities, as well as long-term care facilities (Utah Department of Administrative Services, 2013). Overall, the Utah incident-reporting mandate provides a more detailed list of responsible facilities, making it easier to determine the boundaries of responsibility and accountability in reporting sentinel events.
The types of sentinel events that must be reported by facilities in Minnesota and Utah are almost identical. They include surgical incidents, device and product run-down states, and patient protection problems, sentinel events in care management, environmental issues, as well as criminal cases. The Minnesota incident-reporting mandate identifies a separate class of sentinel events, namely, radiologic ones. These are described as death or serious injury of a patient associated with the introduction of a metallic object into the MRI area (The Office of the Revisor of Statutes, 2014). According to the Agency for Healthcare Research and Quality (n.d.a), it is an example of a never event that is particularly rare in a hospital setting. Nonetheless, it can have devastating impacts on patients and healthcare facilities (Agency for Healthcare Research and Quality, n.d.a). Therefore, it is advisable for the Utah incident-reporting mandate to be reconsidered to include the radiologic events category.
Both incident-reporting systems impose a responsibility for investigating adverse events on incident facilities (The Office of the Revisor of Statutes, 2014; Utah Department of Administrative Services, 2013). However, no specific requirements regarding a department or a person, who must conduct such investigations at a hospital level, are provided. The Utah incident-reporting mandate includes several provisions regarding the participation of the department representative in the process of investigation (Utah Department of Administrative Services, 2013). It also governs the principles of confidentiality and electronic reporting for incident facilities. Unfortunately, neither of the two mandates provides any clear guidelines as to how the confidentiality and privacy of the reported data should be protected. Apparently, hospitals are free to choose the most feasible system of data processing and storage, as long as they meet the requirements established by the administrative code. Incident facilities are not allowed to release the information collected in the process of investigating a sentinel event, since it is considered to be confidential and privileged (Utah Department of Administrative Services, 2013).
A root cause analysis is the fundamental requirement in both incident-reporting systems. This mandatory process follows the occurrence of any sentinel event (The Office of the Revisor of Statutes, 2014; Utah Department of Administrative Services, 2013). However, the Utah incident-reporting mandate is more detailed in terms of how a root cause analysis should be conducted, as well as how its results should be communicated to the department representatives. It can become a good model for health administrators in Minnesota, who seek to advance the role of a root cause analysis in preventing adverse events.
One of the biggest questions is whether mandatory incident reporting systems present a better option as compared to voluntary incident reporting ones. Both systems can facilitate decision-making and aid in court, as well as enable hospital facilities to determine the root causes of a sentinel event (Module 3, 2015). However, they possess unique strengths and weaknesses. On the one hand, voluntary reporting empowers the incident facility personnel to engage in a thorough analysis of the issue. It guarantees more accurate utilization of scarce resources for effective investigation and system changes. It is also known for higher levels of confidentiality and anonymity, which motivate hospital reporters to be more responsible and thorough in reporting an adverse event (Agency for Healthcare Research and Quality, n.d.b). Unfortunately, voluntary reporting fails to create a full picture of sentinel events at hospitals, since administrators are typically reluctant to report serious failures (Agency for Healthcare Research and Quality, n.d.b). It is not the case concerning mandatory systems, which obligate hospitals to report all adverse events and incidents as soon as possible. Yet, mandatory incident reporting systems require the use of rich collaborative resources, objective reporting criteria, comprehensive statutes, and reliable confidentiality guarantees (Flink, Chevalier, Ruperto, Dameron, Heigel, Leslie, Mannion, & Panzer, n.d.). Based on the discussion above, the most effective system would comprise the features of voluntary and mandatory reporting, depending on the type and severity of a sentinel event.
In summary, patient safety remains a matter of urgency in healthcare. State incident reporting mandates govern decisions and actions of healthcare facilities in reporting, investigating, and preventing sentinel events. The incident reporting systems in Minnesota and Utah display considerable legal similarities. They obligate responsible facilities to report adverse events as soon as possible. Mandatory and voluntary incident reporting systems have their strengths and weaknesses. The best system will comprise the elements of voluntary and mandatory reporting, based on the severity and type of a critical incident.
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