New Hampshire Principles for Identifying Serious, Adverse Events for which Payment is Not Expected
New Hampshire hospitals are working every day to make care as safe and free from harm as it can possibly be. They voluntarily monitor and report on many aspects of clinical performance and are proactive in collaborating to identify and share best practices. On the rare occasion when a serious, adverse event that could have been prevented occurs, our hospitals believe information about the error should be quickly and openly communicated to patients and their families. Hospitals will not expect payment or partial payment for care resulting from the preventable error for which they are accountable..
All of these principles must apply and should be based on a thorough root cause analysis:
- The error or event must be preventable. Where
there are evidence-based and nationally recognized practices that are
effective in preventing a particular harm from occurring, and they could
have been implemented by the hospital, the error or event would be
considered preventable.
- The error or event must be within the control of
the hospital. Errors that may have occurred in the manufacture of
drugs, devices or equipment, before the materials reached a hospital’s
doors, or at a referring institution, are examples of events that would be
outside of the hospital’s control.
- The error or event must be the result of a mistake
made in the hospital. These include errors in which a hospital failed
to successfully carry out an evidence-based and nationally recognized
practice that would have, in all probability, prevented harm to the patient.
- The
error or event must result in significant harm. Significant harm is defined
as death or serious physical or psychological injury independent of the
patient’s underlying condition.
- The error or event must be clearly and precisely defined in advance. Specificity is required to identify events. It is recommended that each hospital generate a list of events such as those identified in the National Quality Forum’s, Serious Reportable Events in Health Care.
Adopted by the Board of the New Hampshire Hospital Association, June 18, 2008
