SB 916
Requires hospitals to report adverse health events to a patient safety organization for review
LR Number:
Last Action:
4/8/2008 - Hearing Conducted S Health and Mental Health Committee
Journal Page:
Calendar Position:
Effective Date:
August 28, 2008

Current Bill Summary

SB 916 - This act requires hospitals to report whenever they have a "serious reportable event in health care," as identified by the National Quality Forum. Such events include wrong-site surgery, retention of a foreign object in a patient after surgery, and death or serious disability associated with medication error.

The procedure for hospitals reporting such events to the Department of Health and Senior Services and to a patient safety organization are prescribed in the act. The requirements for a patient safety organization are also prescribed in the act. The patient-identifying data shall be redacted from information provided to the department or patient safety organization. The initial report of the event shall be reported to the patient safety organization and include a description of immediate actions taken by the hospital to minimize the risk of harm to patients and prevent reoccurrence. Within 45 days after the event occurred, the hospital shall submit to the patient safety organization a root cause analysis and a prevention plan, which shall be forwarded to the department.

The department shall investigate the reportable incident and based on its findings, determine whether the hospital’s response and proposed prevention plan is sufficient to reduce the risk of future occurrences of that type. The department shall also periodically evaluate the performance of the patient safety organization regarding report submission processes and its reviews of prevention plans. The act also prescribes the procedure for the department when taking action on insufficient prevention plans.

If a reportable incident is disclosed to the department and patient safety organization and the prevention plan and root cause analysis is submitted and approved by the department, the incident shall not be deemed grounds for a finding of a licensure deficiency. The department shall promulgate rules establishing criteria for defining cases in which reportable incidents have occurred in a hospital with a frequency or possible pattern of adverse outcomes as to necessitate departmental intervention.

The patient safety organization shall in collaboration with the department publish an annual report to the public on reportable incidents. The report shall show the number and rate per patient encounter by region and by category of reportable incident and may identify reportable incidents by type of facility.

This act provides for certain legal protections of patient safety organization documents. The proceedings and records of the organization shall not be subject to discovery or introduction into evidence in any civil action against a provider. However, information otherwise available from original sources shall not be immune from discovery or use in any civil action if they were presented during a patient safety organization meeting. Patient safety work product shall be privileged and confidential and shall not be disclosed for any purpose.

Any hospital that reports a reportable incident shall not charge for or bill any entity for all services related to the reportable incident.

This act is similar to SB 578 (2007).