Wash. Admin. Code § 246-302-020

Current through Register Vol. 24-23, December 1, 2024

Section 246-302-020 - How and when to report

Medical facilities must report confirmed adverse health events to the department. A medical facility must:

(1) Notify the department that an adverse health event has occurred within forty-eight hours of confirmation of the adverse health event. The notification must include:

(a) The name of the medical facility;

(b) The date the adverse event was confirmed;

(c) The type of adverse health event; and

(d) Any additional contextual information the medical facility chooses to provide.

(2) Submit a report to the department within forty-five days of the confirmation of the adverse health event. The report must include a root cause analysis and corrective action plan. The root cause analysis must:

(a) Follow the procedures and methods of:

(i) The joint commission;

(ii) The department of veterans affairs national center for patient safety; or

(iii) Another nationally recognized root cause analysis methodology the department has found acceptable for the type of facility reporting an adverse health event.

(b) Include the following information:

(i) The findings regarding the root cause of the adverse health event;

(ii) The number of patients, registered nurses, licensed practical nurses, and unlicensed assistive personnel present in the relevant patient care unit at the time the reported adverse health event occurred;

(iii) The number of nursing personnel present at the time of the adverse health event who have been supplied by temporary staffing agencies, including traveling nurses; and

(iv) The number of nursing personnel, if any, on the patient care unit working beyond their regularly scheduled number of consecutive hours worked by each such nursing personnel at the time of the adverse health event.

The corrective action plan must be consistent with the findings of the root cause analysis and include:

(A) How each finding will be addressed and corrected;

(B) When each correction will be completed;

(C) Who is responsible to make the corrections;

(D) What action will be taken to prevent the adverse health event from reoccurring; and

(E) A monitoring schedule to assess the effectiveness of the corrective action plan, including who is responsible for the monitoring schedule.

(3) If a medical facility determines there is no need to create a corrective action plan for a particular adverse health event, the medical facility must provide to the department a written explanation of the reasons for not creating a corrective action plan.

(4) The medical facility may amend the notification or report within sixty days of the submission.

(5) The report shall not include any identifying information for any health care professional, facility employee, or patient involved.

(6) Notification and reporting under this rule does not remove a medical facility's responsibility to report a licensed practitioner's unprofessional conduct to the department, as defined under RCW 18.130.180.

Wash. Admin. Code § 246-302-020

Statutory Authority: Chapter 70.56 RCW. 12-16-057, § 246-302-020, filed 7/30/12, effective 10/1/12.