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    Document Summary
    - Report Published -

    Report Document No. 109
    PUBLICATION YEAR 2009

    Document Title
    Various Responses to Medical Errors

    Author
    Joint Commission on Health Care

    Enabling Authority
    30-168.3 (7.)

    Executive Summary
    House Joint Resolution 101, introduced by Delegate John O’Bannon, III during the 2008 General Assembly Session, directed the Joint Commission on Health Care (JCHC) to “study the use of disclosure, apologies, alternative dispute resolution, and other measures in the case of medical errors and adverse medical outcomes and the impact of such measures on the cost and quality of care, patient confidence, and the medical malpractice system.” HJR 101 was not reported by House Rules, with the understanding that JCHC could complete the study without the resolution.

    A study committee was formed that included representatives of defense and plaintiffs’ attorneys, physicians, hospitals, insurers, mediators, the Virginia Bar Association, and the Office of the Attorney General. While significant work was completed during the 10 meetings held in 2008, the study committee concluded that additional information and work was needed. The committee reached consensus on the following recommendation:

    JCHC should convene a Task Force consisting of representatives of the primary stakeholders in this subject area…[and] charge this task force with:

    • developing agreed-upon working definitions of key terms such as adverse outcome, medical error, and disclosures, to facilitate discussions in Virginia of the issues;

    • tracking results and developments in disclosure and resolution programs now operational in Virginia and other states, and federal developments in this area;

    • crafting a model or models for disclosure and early resolution programs that could be offered to Virginia health care providers, insurers and attorneys for their use;

    • should such a model or models be developed, considering ways to incentivize health care providers to try use of such models and to report outcomes of their use with regard to several factors, including cost, claims experience, impact on quality/patient safety efforts and reported patient/provider satisfaction;

    • should the Task Force decide not to offer such model(s), explaining the reasons.

    On behalf of the Joint Commission and staff, I would like to thank the numerous individuals who served on and consulted with the study committee.

    Kim Snead
    Executive Director
    March 2009