76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session
Enrolled
Senate Bill 95
Printed pursuant to Senate Interim Rule 213.28 by order of the
President of the Senate in conformance with presession filing
rules, indicating neither advocacy nor opposition on the part
of the President (at the request of Governor John A. Kitzhaber
for Oregon Health Authority)
CHAPTER ................
AN ACT
Relating to patient safety; creating new provisions; amending ORS
442.831, 442.837 and 677.082; and declaring an emergency.
Be It Enacted by the People of the State of Oregon:
SECTION 1. { + Section 2 of this 2011 Act is added to and made
a part of the Insurance Code. + }
SECTION 2. { + (1) As used in this section:
(a) 'Adverse event' means a negative consequence of patient
care that is unanticipated, is usually preventable and results in
or presents a significant risk of patient injury.
(b) 'Claim' means a written demand for restitution for an
injury alleged to have been caused by the medical negligence of a
health practitioner or licensed health care facility.
(c) 'Health practitioner' means a person described in ORS
31.740 (1).
(d) 'Patient's family' includes:
(A) A parent, sibling or child by marriage, blood, adoption or
domestic partnership.
(B) A foster parent or foster child.
(2) An insurer may not decline or refuse to defend or indemnify
a health practitioner or a health care facility with respect to a
claim, for any reason that is based on the disclosure to the
patient or the patient's family by the health practitioner or
facility of an adverse event or information relating to the cause
of an adverse event.
(3) A policy or contract of insurance or indemnity may not
include a provision or term excluding or limiting coverage based
on the disclosure to a patient or the patient's family by a
health practitioner or facility of an adverse event or
information relating to the cause of an adverse event. + }
SECTION 3. ORS 442.831 is amended to read:
442.831. (1) Except as otherwise provided in ORS 442.819 to
442.851, the Oregon Patient Safety Commission Board of Directors,
or officials of the Oregon Patient Safety Commission acting under
the authority of the board, shall exercise all the powers of the
commission and shall govern the commission. The board shall adopt
rules necessary for the implementation of the Oregon Patient
Safety Reporting Program, including but not limited to:
Enrolled Senate Bill 95 (SB 95-A) Page 1
(a) Developing a list of objective and definable serious
adverse events to be reported by participants. In developing this
list, the board shall consider similar lists developed in other
states and nationally. The board may change the list from time to
time. { - The first list developed by the board shall focus on
serious adverse events that caused death or serious physical
injury. Later lists may include, in the discretion of the board,
serious adverse events that did not cause death or serious
physical injury but posed a significant risk of death or a risk
of significant physical injury. - }
(b) Developing a budget.
(c) Establishing a process to seek grants and other funding
from federal and other sources.
(d) Establishing a method to determine participant fees, if
necessary.
(e) Establishing auditing and oversight procedures, including a
process to:
(A) Assess completeness of reports from participants;
(B) Assess credibility and thoroughness of root cause analyses
submitted to the program;
(C) Assess the acceptability of action plans and participant
follow-up on the action plan; and
(D) Obtain certification by the Public Health Officer on the
completeness, credibility, thoroughness and acceptability of
participant reports, root cause analyses and action plans.
(f) Establishing criteria for terminating a participant from
the program. Incomplete reporting, failure to comply with ORS
442.837 (4) or failure to adequately implement an action plan are
grounds for termination from the program.
(2) The board may not use or disclose patient safety data
reported, collected or developed pursuant to ORS 442.819 to
442.851 for purposes of any enforcement or regulatory action in
relation to a participant.
(3) The board shall maintain the confidentiality of all patient
safety data that identifies or could be reasonably used to
identify a participant or an individual who is receiving or has
received health care from the participant.
SECTION 4. ORS 442.837 is amended to read:
442.837. (1) The Oregon Patient Safety Reporting Program is
created in the Oregon Patient Safety Commission to develop a
serious adverse event reporting system. The program shall include
but is not limited to:
(a) Reporting by participants, in a timely manner and in the
form determined by the Oregon Patient Safety Commission Board of
Directors established in ORS 442.830, of the following:
(A) Serious adverse events;
(B) Root cause analyses of serious adverse events;
(C) Action plans established to prevent similar serious adverse
events; and
(D) Patient safety plans establishing procedures and protocols.
(b) Analyzing reported serious adverse events, root cause
analyses and action plans to develop and disseminate information
to improve the quality of care with respect to patient safety.
This information shall be made available to participants and
shall include but is not limited to:
(A) Statistical analyses;
(B) Recommendations regarding quality improvement techniques;
(C) Recommendations regarding standard protocols; and
(D) Recommendations regarding best patient safety practices.
Enrolled Senate Bill 95 (SB 95-A) Page 2
(c) Providing technical assistance to participants, including
but not limited to recommendations and advice regarding
methodology, communication, dissemination of information, data
collection, security and confidentiality.
(d) Auditing participant reporting to assess the level of
reporting of serious adverse events, root cause analyses and
action plans.
(e) Overseeing action plans to assess whether participants are
taking sufficient steps to prevent the occurrence of serious
adverse events.
(f) Creating incentives to improve and reward participation,
including but not limited to providing:
(A) Feedback to participants; and
(B) Rewards and recognition to participants.
(g) Distributing written reports using aggregate, de-identified
data from the program to describe statewide serious adverse event
patterns and maintaining a website to facilitate public access to
reports, as well as a list of names of participants. The reports
shall include but are not limited to:
(A) The types and frequencies of serious adverse events;
(B) Yearly serious adverse event totals and trends;
(C) Clusters of serious adverse events;
(D) Demographics of patients involved in serious adverse
events, including the frequency and types of serious adverse
events associated with language barriers or ethnicity;
(E) Systems' factors associated with particular serious adverse
events;
(F) Interventions to prevent frequent or high severity serious
adverse events;
(G) Analyses of statewide patient safety data in Oregon and
comparisons of that data to national patient safety data; and
(H) Appropriate consumer information regarding prevention of
serious adverse events.
(2) Participation in the program is voluntary. The following
entities are eligible to participate:
(a) Hospitals as defined in ORS 442.015;
(b) Long term care facilities as defined in ORS 442.015;
(c) Pharmacies licensed under ORS chapter 689;
(d) Ambulatory surgical centers as defined in ORS 442.015;
(e) Outpatient renal dialysis facilities as defined in ORS
442.015;
(f) Freestanding birthing centers as defined in ORS 442.015;
and
(g) Independent professional health care societies or
associations.
(3) Reports or other information developed and disseminated by
the program may not contain or reveal the name of or other
identifiable information with respect to a particular participant
providing information to the commission for the purposes of ORS
442.819 to 442.851, or to any individual identified in the report
or information, and upon whose patient safety data, patient
safety activities and reports the commission has relied in
developing and disseminating information pursuant to this
section.
(4) After a serious adverse event occurs, a participant must
provide written notification in a timely manner to each patient
served by the participant who is affected by the event. Notice
provided under this subsection may not be construed as an
admission of liability in a civil action.
Enrolled Senate Bill 95 (SB 95-A) Page 3
{ + (5) The commission shall collaborate with providers of
ambulatory health care to develop initiatives to promote patient
safety in ambulatory health care. + }
SECTION 5. ORS 677.082 is amended to read:
677.082. (1) For the purposes of any civil action against a
person licensed by the Oregon Medical Board { + or a health care
institution, health care facility or other entity that employs
the person or grants the person privileges + }, any expression of
regret or apology made by or on behalf of the person, { + the
institution, the facility or other entity, + } including an
expression of regret or apology that is made in writing, orally
or by conduct, does not constitute an admission of liability
{ - for any purpose - } .
(2) A person who is licensed by the Oregon Medical Board, or
any other person who makes an expression of regret or apology on
behalf of a person who is licensed by the Oregon Medical Board,
may not be examined by deposition or otherwise in any civil or
administrative proceeding, including any arbitration or mediation
proceeding, with respect to an expression of regret or apology
made by or on behalf of the person, including expressions of
regret or apology that are made in writing, orally or by conduct.
SECTION 6. { + Section 2 of this 2011 Act applies to insurance
policies issued or renewed on or after the effective date of this
2011 Act. + }
SECTION 7. { + This 2011 Act being necessary for the immediate
preservation of the public peace, health and safety, an emergency
is declared to exist, and this 2011 Act takes effect on its
passage. + }
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Passed by Senate March 23, 2011
.............................................................
Robert Taylor, Secretary of Senate
.............................................................
Peter Courtney, President of Senate
Passed by House May 5, 2011
.............................................................
Bruce Hanna, Speaker of House
.............................................................
Arnie Roblan, Speaker of House
Enrolled Senate Bill 95 (SB 95-A) Page 4
Received by Governor:
......M.,............., 2011
Approved:
......M.,............., 2011
.............................................................
John Kitzhaber, Governor
Filed in Office of Secretary of State:
......M.,............., 2011
.............................................................
Kate Brown, Secretary of State
Enrolled Senate Bill 95 (SB 95-A) Page 5