Assembly Concurrent Resolution No. 7–Committee on
Health and Human Services

 

FILE NUMBER..........

 

ASSEMBLY Concurrent RESOLUTION—Directing the Legislative Committee on Health Care to conduct an interim study concerning the development of a system for reporting medical errors.

 

   Whereas, At least 44,000 persons die each year in hospitals in the

United States from preventable medical errors, making preventable

medical errors a leading cause of death in this country, exceeding the

number of deaths attributable to motor vehicle accidents, breast cancer or

AIDS; and

   Whereas, In addition to the unfortunate consequences suffered by

many patients and families as a result of preventable medical errors, the

direct and indirect costs borne by the nation as a result of preventable

medical errors, including, without limitation, higher expenditures for health

care, lost productivity, costs related to disabilities and costs for personal

care, are approximately $17 billion annually; and

   Whereas, Establishing a reporting system for medical errors is an

effective way to improve the safety of patients in this state and reduce the

number of preventable medical errors that occur in this state by gathering

sufficient information about medical errors from multiple sources to

attempt to understand the factors that contribute to the errors and then

using this information to prevent the recurrence of such errors throughout

the health care system; now, therefore, be it

   Resolved by the Assembly of the State of Nevada, the Senate

Concurring, That the Legislative Committee on Health Care is hereby

directed to appoint a subcommittee to conduct an interim study concerning

the development of a system for reporting medical errors in this state; and

be it further

   Resolved, That the study must include, without limitation:

   1.  A determination of what constitutes:

   (a) A medical error;

   (b) An outcome that is detrimental to a patient; and

   (c) A medical error that causes an outcome which is detrimental to a

patient.

   2.  A comprehensive evaluation of:

   (a) Systems for reporting medical errors that are designed to:

     (1) Inform patients of the occurrence of medical errors that cause

outcomes which are detrimental to patients;

     (2) Ensure that preventable medical errors are not systematically

repeated; and

     (3) Encourage medical institutions to improve the safety of their

patients;

   (b) Whether such a system should be established in this state;

   (c) Effective manners in which the system may impose mandatory

reporting of medical errors;

   (d) Methods for ensuring that information reported to the system

concerning the identity of a specific patient or medical professional

remains confidential to encourage the reporting of medical errors and to

ensure that the system does not encourage blaming an individual medical

professional for a medical error;

   (e) The proper use of the information that is reported to the system,

including, without limitation, whether standards should be established for

using the information to prevent or reduce preventable medical errors;

   (f) Which medical and other related facilities, medical professionals and

pharmacies should be required to report information concerning medical

errors to the system;

   (g) Whether sanctions should be imposed on a medical professional

who fails to comply with the reporting requirements of the system; and

   (h) The relationship between medical errors and the licensing of

medical professionals, and the manner in which the system may be

coordinated with the licensing of medical professionals to reduce medical

errors.

   3.  The use of the report To Err is Human: Building a Safer Health

System that was released by the Institute of Medicine in November, 1999;

and be it further

   Resolved, That no action may be taken by the subcommittee on

recommended legislation unless it receives a majority vote of the Senators

on the subcommittee and a majority vote of the Assemblymen on the

subcommittee; and be in further

   Resolved, That the Legislative Committee on Health Care shall submit

a report of the results of the study and any recommendations for legislation

to the 72nd session of the Nevada Legislature.

 

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