AI-assisted research summary: The commissioner must establish and run an adverse health event reporting system to improve quality, not to punish errors.
I. The commissioner shall establish an adverse health event reporting system designed to facilitate quality improvement in the health care system. The reporting system shall not be designed to punish errors by health care practitioners or health care facility employees. II. The reporting system shall consist of: (a) Mandatory reporting by facilities of adverse health care events. (b) Mandatory completion of a root cause analysis and a corrective action plan by the facility and reporting of the findings of the analysis and the plan to the commissioner or reporting of reasons for not taking corrective action. (c) Analysis of reported information by the commissioner to determine patterns of systemic failure in the health care system and successful methods to correct these failures. (d) Sanctions against facilities for failure to comply with reporting system requirements. (e) Communication from the commissioner to health care facilities, health care purchasers, and the public to maximize the use of the reporting system to improve health care quality. III. The commissioner is not authorized to select from or between competing alternate acceptable medical practices. IV. The commissioner shall: (a) Analyze adverse event reports, corrective action plans, and findings of the root cause analyses to determine patterns of systemic failure in the health care system and successful methods to correct these failures. (b) Communicate to individual facilities the commissioner's conclusions, if any, regarding an adverse event reported by the facility. (c) Communicate with relevant health care facilities any recommendations for corrective action resulting from the commissioner's analysis of submissions from facilities. (d) Publish an annual report describing, by facility, adverse events reported, outlining, in aggregate, corrective action plans and the findings of root cause analyses and making recommendations for legislation relative to state health care operations. V. The commissioner shall report the list of reportable events under this section to the National Quality Forum and, working in coordination with the National Quality Forum, to the other states. The commissioner shall monitor discussions by the National Quality Forum of amendments to the forum's list of reportable events and shall report to the general court whenever the list needs to be modified. The commissioner shall also monitor implementation efforts in other states to establish a list of reportable events and shall make recommendations to the general court as necessary for modifications in the New Hampshire list or in the other components of the New Hampshire reporting system to keep the system as nearly uniform as possible with similar systems in other states. VI. The commissioner shall notify each hospital and ambulatory surgery center when the National Quality Forum publishes an amendment to the serious reportable events and specifications and immediately upon such notification, the amended serious reportable events and specifications shall be the reportable adverse events pursuant to this subdivision. VII. Nothing in this section shall be construed to limit the responsibilities and duties of the department under RSA 151. Source: Source. 2009, 287:2, eff. Jan. 1, 2010. 2013, 27:2, eff. July 15, 2013.