CHAPTER 151 RESIDENTIAL CARE AND HEALTH FACILITY LICENSING
Adverse Events Reporting System
Section 151:38
151:38 Hospitals and Ambulatory Surgical Centers Required to Report Adverse Events. –
I. Any hospital or ambulatory surgical center licensed pursuant to this chapter shall report to the commissioner the occurrence of any of the adverse health care events described in subparagraphs (a) and (b) as soon as is reasonably and practically possible, but no later than 15 working days after discovery of the event. The report shall be filed in a format specified by the commissioner and shall identify the facility but shall not include any identifying information for any of the health care professionals, facility employees, or patients involved. The commissioner may consult with experts and organizations familiar with patient safety when developing the format for reporting and in further defining events in order to be consistent with industry standards. Events to be reported under this subdivision include:
(a) Serious reportable events and specifications published and periodically amended by the National Quality Forum, which are incorporated in this subdivision by reference. The department shall provide a link from its Internet website to the serious reportable events and specifications on the National Quality Forum Internet website and shall provide a printed copy upon request.
(b) The exposure of a patient to a non-aerosolized bloodborne pathogen by a health care worker's intentional, unsafe act. An act by hospital or ambulatory surgery center staff resulting in an infection or disease shall be considered to be purposefully unsafe if it meets all of the following criteria:
(1) There was an intentional act or reckless behavior;
(2) No reasonable person with similar qualifications, training, and experience would have acted the same way under similar circumstances; and
(3) There were no extenuating circumstances that could justify the act.
II. Following the occurrence of an adverse health care event, the facility shall conduct a root cause analysis of the event. Following the analysis, the facility shall implement a corrective action plan to implement the findings of the analysis or report to the commissioner any reasons for not taking corrective action. If the root cause analysis and the implementation of a corrective action plan are complete at the time an event must be reported, the findings of the analysis and the corrective action plan shall be included in the report of the event. The findings of the root cause analysis and a copy of the corrective action plan shall otherwise be filed with the commissioner within 60 days of the event.
III. All information and data made available to the department and its designees under this section shall be confidential and shall be exempt from public access under RSA 91-A.