An Act To Amend Sentinel Events Reporting Laws To Reduce Medical Errors and Improve Patient Safety
Sec. 1. 22 MRSA §8752, as enacted by PL 2001, c. 678, §1 and affected by §3 and corrected by RR 2001, c. 2, Pt. A, §37 and affected by §38 and amended by PL 2007, c. 324, §17, is further amended to read:
§ 8752. Definitions
As used in this chapter, unless the context otherwise indicates, the following terms have the following meanings.
(1) An unanticipated death; or
(2) A major permanent loss of function that is not present when the patient is admitted to the health care facility;
Sec. 2. 22 MRSA §8753, as enacted by PL 2001, c. 678, §1 and affected by §3, is amended to read:
§ 8753. Mandatory reporting of sentinel events
A health care facility shall report to notify the division a sentinel event that occurs to a patient while the patient is in the health care facility as provided in this section whenever a sentinel event has occurred, as provided in this chapter.
(1) A thorough root cause analysis must include: a determination of the human and other factors most directly associated with the sentinel event and the processes and systems related to its occurrence; an analysis of the underlying systems and processes to determine where redesign might reduce risk; an inquiry into all areas appropriate to the specific type of event; an identification of risk points and their potential contributions to the event; a determination of potential improvement in processes or systems that would tend to decrease the likelihood of such an event in the future or a determination, after analysis, that no such improvement opportunities exist; an action plan that identifies changes that can be implemented to reduce risks or formulates a rationale for not undertaking such changes; and, where improvement actions are planned, an identification of who is responsible for implementation, when the action will be implemented and how the effectiveness of the action will be evaluated.
(2) A credible root cause analysis must include participation by the leadership of the health care facility and by the individuals most closely involved in the processes and systems under review, is internally consistent without contradictions or unanswered questions, provides an explanation for all findings, including those identified as "not applicable" or "no problem," and includes the consideration of any relevant literature.
(3) The root cause analysis submitted to the division may exclude protected professional competence review information pursuant to the Maine Health Security Act.
Sec. 3. 22 MRSA §8753-A is enacted to read:
§ 8753-A. Standardized procedure
A health care facility shall have a written standardized procedure for the identification of sentinel events. The division shall develop the standardized reporting and notification procedures by adoption of routine technical rules under Title 5, chapter 375, subchapter 2-A.
Sec. 4. 22 MRSA §8754, sub-§1, as enacted by PL 2001, c. 678, §1 and affected by §3, is amended to read:
Sec. 5. 22 MRSA §8754, sub-§3, as enacted by PL 2001, c. 678, §1 and affected by §3, is amended to read:
(1) Subject to public access under Title 1, chapter 13, except for data developed from the reports that do not identify or permit identification of the health care facility;
(2) Subject to discovery, subpoena or other means of legal compulsion for its release to any person or entity; or
(3) Admissible as evidence in any civil, criminal, judicial or administrative proceeding.
(1) Any final administrative action;
(2) Information independently received pursuant to a 3rd-party complaint investigation conducted pursuant to department rules; or
(3) Information designated as confidential under rules and laws of this State.
This subsection does not affect the obligations of the department relating to federal law.
Sec. 6. 22 MRSA §8754, sub-§4, as enacted by PL 2001, c. 678, §1 and affected by §3, is amended to read:
Sec. 7. 22 MRSA §8755, as enacted by PL 2001, c. 678, §1 and affected by §3, is repealed and the following enacted in its place:
§ 8755. Compliance
Sec. 8. Authority to submit legislation. After reviewing recommendations in the CY 2008 Sentinel Events report dated April 28, 2009, the Joint Standing Committee on Health and Human Services may submit legislation related to the recommendations of the report to the Second Regular Session of the 124th Legislature.