Mandatory reporting for never events jumps

More states are mandating adverse event reporting, and this trend could have a significant impact on healthcare providers, says Kathryn Schulke, BSN, a principal with the law firm of Booz Allen Hamilton in Rockville, MD. Twenty-seven states and the District of Columbia have passed legislation requiring adverse event reporting, she says.

One risk is that the reporting systems can provide a false impression of patient safety at hospital, Schulke says.

"Many of the adverse events that must be reported cannot be validated by an outside entity," Schulke says. "A fall is an adverse event, but a fall that is caught is a near miss. So if you have a lot of falls and don't honor the reporting, you look like a provider with fewer falls than a hospital that is enthusiastic about reporting all falls and near misses."

Schulke expects that the number of states requiring adverse event reporting will continue to rise, and she also says the legislation is likely to be expanded to include hospital-acquired conditions. Physician reporting of adverse events also might be made available, she says. (For a list of the states that require adverse event reporting and information on each state's reporting system, go to The page opens with California's rules because it is the first alphabetically, but the other states can be selected on the right side.)

States protect the information transmitted to state agencies concerning adverse events, meaning the information cannot be used against the provider in a lawsuit, so that is not a direct threat. Mandatory adverse event reporting can cause other headaches, however. Third-party payers are increasingly hesitant to pay for poor care, and reporting an adverse event might result in non-payment for all of the care rendered, even if the adverse event was relatively small and benign, Schulke says. The reports also could be detrimental to hospitals amidst the push for more value-based purchasing.

"There is not 100% alignment between the events that must be reported under mandatory adverse event reporting and what is reported for value-based purchasing, but there is enough alignment that it should leave behooves risk managers and chief medical officers to really take an aggressive approach to reducing those errors," Schulke says. "Not only are they going to be reported, but in the very near future they are going to affect reimbursement."

Risk managers should start by determining whether their hospital or system is a poor performer in comparison to national averages or error rates in their communities, Schulke says. "Then you have to drill down in your own organization and look at those individual units – the surgical unit, the emergency department – where those numbers are not good," she says. "The risk manager needs to narrow down where the risk is and then address that risk with specific solutions."

The good news is that there is substantial federal funding available for reducing adverse events and improving patient safety, Schulke notes. The Center for Medicare and Medicaid Innovation (CMMI) announced it will provide $500 million in funding to selected local and statewide entities to coordinate the implementation of projects under the Partnership for Patients initiative.

"To my knowledge, this is the first time that the government has had this large of an effort to fund and help hospitals make patient safety improvements," Schulke says. "If I were a hospital risk manager, I'd sign up for this right away. It's virtually free of charge to the hospital if you agree to work on seven out of a list of 10 areas of harm."


• Kathryn Schulke, BSN, Principal, Booz Allen Hamilton, Rockville, MD. Telephone: (410) 443-1589. E-mail: