Joanna K. Weinberg, JD, LLM, Associate Adjunct Professor of Health Law, Policy and Ethics, UC San Francisco- Department of Social and Behavioral Sciences, Box 0646 Laurel Heights Suite 340, San Francisco, CA 94118, 415-502-5204, weinbgj@itsa.ucsf.ed and Lee Hilborne, MD, MPH, Pathology and Laboratory Medicine, David Geffen School of Medicine, UCLA, Medl Cntr-Pat Safety & Quality, 924 Wstwd Bl, Ste 90, Los Angeles, CA 90095.

The IOM Reports on patient safety heightened awareness of increasing injuries from medical errors. In response, healthcare institutions have intensified attention to the dimensions of quality improvement, introduced concrete technological improvements such as computerized order entry and surgical site marking; and have developed adverse incident reporting systems (IR). This paper looks at the emergence of state laws mandating IR or IR systems, in light of similar activities by health care institutions, regulatory bodies and professional associations: Incident reporting is a mechanism used within a care -system to systematically describe and account for actions that may or have harmed patients, and is recognized as a forum for uniform data collection and for transforming institutional culture. The research examines the content and scope of state IR laws. States vary in the components of IR mandates: mandatory versus voluntary reporting; the definition of a "reportable event;" and external oversight. The scope of such systems is equally varied. Structures and scope include: 1. A focus on specific types of errors (1.e., medication errors) or systems (emergency department, anesthesiology); 2. Use of specific information technology; 3. Use of reporting primarily for education and training; and 4. Design of a broad-based reporting system.

This paper explores the conceptual bases for this variation, focusing in particular on whether the proliferation of these systems represents “healthy experimentation” or a hodgepodge of conflicting mandates, and the potential for conflict between new norms of disclosure and existing norms of risk management.

Learning Objectives:

(
• To develop awareness of the relationship between individual medical errors or mistakes and the institutional system within which errors or mistakes occur; (
• To inform participants about the emergence of legislative tools to combat breakdowns in patient safety; and (
• To engage participants in a critical discussion about the strengths and weakness of the shifting norms of risk and disclosure within the healthcare system.

Keywords: Quality Improvement, Health Care Quality

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.