Frequently Asked Questions (FAQs)
What is an adverse event?
Adverse Events are medical errors healthcare facilities could and should have avoided. The
National Quality Forum (NQF) defines an adverse event as a preventable, serious, and unambiguous occurrence or error at a healthcare facility which is universally or largely preventable and should never occur. The Department of Health uses the
NQF 2006 Update to identify 28
reportable events and provides guidance on defining these events.
Top of Page
What types of healthcare facilities are required to report the occurrence of adverse events?
The law requires
hospitals,
psychiatric hospitals,
child birthing centers,
Department of Corrections medical facilities, and
ambulatory surgical facilities to report to the department when an adverse event occurs.
What adverse event information is available to the public?
Adverse events reported to the department are aggregated and published as
quarterly reports. We cannot release confidential, identifying information about patients or staff involved in an event. We also do not release the root cause analysis associated with an event.
Top of Page
How does my facility determine if a medical error is an adverse event?
Review the list of 28 reportable events. The
NQF 2006 Update provides specification and guidance in defining reportable events. You can find more information on our
resources webpage.
What does state law require of healthcare facilities if they identify an adverse event?
Facilities must notify the Department of Health Adverse Event Reporting Program within 48 hours of confirming an event. Facilities must also submit a root cause analysis within 45 days. The notification form lists the information facilities must provide to the department. This form lists the available methods for reporting. For conducting and preparing a root causes analysis, visit the
resource webpage for guidance.
Top of Page
How does my facility report an adverse event to the Department of Health?
Complete the notification form and contact the department. We prefer you notify the department by phone at (888) 524-6257, fax (360) 236-2830, or email to
AdverseEventReporting@doh.wa.gov. You can also mail the notification form to:
Washington State Department Of Health, Adverse Event, P.O. Box 47853, Olympia, WA 98504-7853.
What is the required reporting time frame for reporting an adverse event?
A healthcare facility must report an event to the department within 48 hours of confirming the event. The facility can also provide contextual information at that time. Facilities must submit a root cause analysis within 45 days after confirmation of an event.
Top of Page
What is contextual information? Do I have to complete one when reporting an adverse event?
The contextual information form is an optional document. A facility may want to provide more information when reporting an adverse event. We publish this contextual information with the quarterly reports.
What is a root cause analysis?
A root cause analysis (RCA) is a system-based review of an adverse event. You use it to determine what happened, why it happened, and what can be done to prevent it from happening again. Facilities must submit a RCA within 45 days of confirming an event. Information in the root cause analysis is confidential and the department will not release content from a RCA. You can find more guidance in conducting and preparing a RCA on the
resources webpage.
Top of Page
How do I conduct a root cause analysis? Are there more resources that are helpful?
We outlined a step-by-step guide to help in completing a root cause analysis. You can find more online resources on the
resources webpage.
Are there any other reporting responsibilities of the facilities?
Yes, the department implemented a quarterly check-in survey for facilities that do not have an adverse event to report. Facilities are asked to notify the department every three months whether or not they had an adverse event. The department emails the survey link to each facility after the end of each reporting quarter.
What is the Check-in Survey?
We implemented a check-in survey requesting facilities to notify the department every quarter as to whether or not they had an adverse event. Facilities notify us with an email survey. The department follows-up with facilities that do not respond to the email survey. The department includes results of the check-in survey in the quarterly reports.
Top of Page
What are the consequences of not reporting an adverse event? Will adverse event reporting impact my licensing survey?
The law requires health care facilities to report when one of the
28 adverse events occurs. Facilities must conduct a root cause analysis and send those findings to the department. The Adverse Event Program is separate from Health Care Facility Licensing Programs.
The department cannot cite a facility for not reporting an event. However, the department may cite a health care facility when conducting a licensing survey if:
- It identifies a possible adverse event and the facility failed to follow the adverse event requirements.
- It receives a complaint about an adverse event and the findings of the investigation determine citations.
Top of Page
Why are facilities required to report if they are not cited for an event?
The intent of the law is to create a system for enhancing accountability and transparency. It is not based on an approach of blame, shame, or punishment. Policymakers hope to foster a culture of learning and enhancing patient safety. The reporting law drives quality improvement in facilities as part of a statewide patient safety vision.
Who do I contact for consultation on definitions or for a site visit?
The Adverse Event Patient Safety Officer position in not filled. The position is proposed for elimination in the 2011-13 biennium budget. We encourage facilities to review the guidance offered on the
resources webpage.
Top of Page
| 
