2003 Minnesota Statutes

     144.7067 Commissioner duties and responsibilities. 

    Subdivision 1.    Establishment of reporting system.  (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. 

    Subd. 2.    Duty to analyze reports; communicate findings. 
  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. 

    Subd. 3.    Sanctions.  (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. 

    HIST: 2003 c 99 s 4