COUNTY OF SAN MATEO

Inter-Departmental Correspondence

Board of Supervisors

DATE:

July 19, 2005

BOARD MEETING DATE:

July 26, 2005

SPECIAL NOTICE/HEARING:

No

VOTE REQUIRED:

Majority

TO:

Honorable Board of Supervisors

FROM:

Supervisor Mark Church and Supervisor Jerry Hill

SUBJECT:

Reporting of Adverse Events in the Provision of Health Care That Occur in County Operated Health Facilities

RECOMMENDATION:

ADOPT AN ORDINANCE ADDING CHAPTER 2.207 TO THE SAN MATEO COUNTY ORDINANCE CODE REGARDING REPORTING OF ADVERSE EVENTS IN THE PROVISION OF HEALTH CARE THAT OCCUR IN COUNTY OPERATED HEALTH CARE FACILITIES

BACKGROUND:

Medical errors occur within all health care systems, primarily due to system failure.

In December 2004, Supervisors Church and Nevin brought an ordinance to the Board which would have required county health care workers and encouraged members of the public to report medical errors in patient care. The matter was continued to April 2005. At the Board meeting in April, we agreed to serve on a subcommittee to draft a mutually acceptable ordinance to bring to the full Board for action in late July 2005. County Counsel was instructed to draft an ordinance that addressed concerns in the following areas: definition of “reportable event”, the time frame for reporting, the role of the Hospital Board of Trustees and the incorporation of public reporting.

DISCUSSION:

The proposed ordinance addresses each one of these concerns. Highlights of the ordinance presented for introduction are as follows:

1.

The ordinance will promote quality patient care and accountability to the public through the disclosure of medical errors. It requires that all health care employees and contractors in County operated health care facilities be required, and all patients and members of the public be strongly encouraged, to report medical errors through established channels within the County organization.

2.

For purposes of reporting obligations, this ordinance requires the reporting of all “adverse events,” which is broadly defined as “an unintended situation that arises from an error in medical diagnosis, procedure, equipment, product, medication, or other patient care that results in death or serious injury.”

3.

Significantly, this ordinance provides specific examples (in terms that the public can understand) of reportable events. The examples are derived from the National Quality Forum’s (NQF) List of 27 Serious Reportable Events. The NQF is a nationally renowned not-for profit membership organization created to develop and implement a national strategy for health care quality management and reporting.

4.

This ordinance also ensures that the patient and/or his/her immediate family is notified of a medical error.

5.

For events that occur at the SMMC, this ordinance provides a role for the San Mateo Medical Center Hospital Board, which is separately charged with oversight responsibility for hospital quality care.

6.

The ordinance also ensures that the County Manager is notified of all adverse events within 24 hours. Further, the County Manager and County Counsel are required to provide the Board of Supervisors with a summary of the event, as appropriate. Moreover, this ordinance requires that the CEOs of the SMMC and Health Department submit a semi-annual summary report to the Board delineating the types of reports that have been made and the implementation of significant changes as a result of such reports.

7.

This ordinance ensures that all reporting is done consistent with state and federal privacy laws.

8.

This ordinance specifically prohibits retaliation or reprisal for making a report.

The proposed ordinance was distributed in late May to the CEO of the Medical Center, the Medical Center’s Board of Trustees, the Director of Health Services, and the Chief of Staff of SMMC for their review and input. At the request of the Health Services Agency we added some clarifying language regarding its identity. The primary concern of the Medical Center CEO and the Chief of Staff is the semi-annual summary report to the Board listing the types of reports that have been made and the implementation of significant changes as a result of such reports. The basis of apprehension ranges from potential violations of patient privacy to a risk of discrediting the hospital. We are confident that this summary report will be done in such a manner as to not identify an individual patient or specific occurrence so as to violate patient confidentiality. Additionally, because this reporting will assist County leaders in making all necessary changes to improve health care provided by the County, we believe the public’s trust in the hospital will increase rather than decrease.

FISCAL IMPACT:

None.