RTI International—Division of Health Services and Social Policy Research
Background: Serious adverse events that occur in hospitals rank as a leading cause of preventable death in the United States. Many states operate reporting systems to monitor and publicly report serious adverse events, a subset that falls under Medicare’s Hospital-Acquired Conditions (HACs). Purpose(s): Identify and describe state efforts, and the supporting role of federal initiatives, to track and report HACs and other serious adverse events. Data Sources: Document review of state and federal reports, databases, and policies for HACs and other serious adverse events; conduct semi-structured telephone interviews with state health department officials and directors of patient safety organizations. Results: Thirty-two states and the District of Columbia (D.C.) track at least one Medicare HAC. Five states collect nearly all ten Medicare HACs (9–10). Eighteen states and D.C. track events through both a state-based reporting system and the Centers for Disease Control National Healthcare Safety Network (NHSN) for health-care associated infections (HAI). For serious adverse events, most states either partially or fully adopted the National Quality Forum’s Serious Reportable Events. For HAIs, thirty states and D.C. mandate reporting through NHSN. States interviewed reported that Medicare’s choice of HACs for nonpayment had at least a partial influence on which serious adverse events required reporting. Conclusions: Many states use the collected data on HACs and other events for quality improvement initiatives and to provide greater transparency through public reporting. More work and research is needed to develop a national reporting system template that has standard definitions, methodology, and reporting.
Keywords: Medicare, Medicaid, qualitative research, quality of care, patient safety (measurement), state health policies