(a) The commissioner shall establish an adverse health event reporting system designed to facilitate quality improvement in the health care system. The reporting system shall not be designed to punish errors by health care practitioners or health care facility employees.
(b) The reporting system shall consist of:
(1) mandatory reporting by facilities of 27 adverse health care events;
(2) mandatory completion of a root cause analysis and a corrective action plan by the facility and reporting of the findings of the analysis and the plan to the commissioner or reporting of reasons for not taking corrective action;
(3) analysis of reported information by the commissioner to determine patterns of systemic failure in the health care system and successful methods to correct these failures;
(4) sanctions against facilities for failure to comply with reporting system requirements; and
(5) communication from the commissioner to facilities, health care purchasers, and the public to maximize the use of the reporting system to improve health care quality.
(c) The commissioner is not authorized to select from or between competing alternate acceptable medical practices.
The commissioner shall:
(1) analyze adverse event reports, corrective action plans, and findings of the root cause analyses to determine patterns of systemic failure in the health care system and successful methods to correct these failures;
(2) communicate to individual facilities the commissioner's conclusions, if any, regarding an adverse event reported by the facility;
(3) communicate with relevant health care facilities any recommendations for corrective action resulting from the commissioner's analysis of submissions from facilities; and
(4) publish an annual report:
(i) describing, by institution, adverse events reported;
(ii) outlining, in aggregate, corrective action plans and the findings of root cause analyses; and
(iii) making recommendations for modifications of state health care operations.
(a) The commissioner shall take steps necessary to determine if adverse event reports, the findings of the root cause analyses, and corrective action plans are filed in a timely manner. The commissioner may sanction a facility for:
(1) failure to file a timely adverse event report under section 144.7065, subdivision 1; or
(2) failure to conduct a root cause analysis, to implement a corrective action plan, or to provide the findings of a root cause analysis or corrective action plan in a timely fashion under section 144.7065, subdivision 8.
(b) If a facility fails to develop and implement a corrective action plan or report to the commissioner why corrective action is not needed, the commissioner may suspend, revoke, fail to renew, or place conditions on the license under which the facility operates.