Patient Safety

Internal Hospital Procedures

Each Vermont hospital must:

• Establish internal policies and procedures to identify, track and analyze all adverse events and near misses
• Conduct appropriate causal analysis
• Develop and implement corrective action plans

External Reports

Each Vermont hospital must report to the Patient Safety Surveillance and Improvement System incidences of any of the National Quality Forum’s serious reportable events and for each event:

• Conduct an appropriate causal analysis
• Develop and implement a corrective action plan
• File the causal analysis and corrective action plan with the Patient Safety Surveillance and Improvement System
• Each hospital must report any incidence of intentional unsafe acts

A yearly summary report of Vermont Hospital's Serious Reportable Events can be found in the annual Hospital Report Card

Causal Analysis and Corrective Action Plan

Intentional Unsafe Act

Reportable Adverse Event

The Patient Safety Surveillance and Improvement System is designed to improve patient safety. As provided for in 18 V.S.A. §1917, all information made available to the Department of Health through the Patient Safety Surveillance and Improvement System is:

• Confidential and privileged
• Exempt from the public access to records law
• Immune from subpoena or other disclosure and not subject to discovery or introduction into evidence in any civil or administrative action against a provider of professional health services

The Intentional Unsafe Act provisions of the Patient Safety Surveillance and Improvement System became effective on July 1, 2006, and the remaining provisions on January 1, 2008.

• Final Rule - Patient Safety Surveillance and Improvement System
• National Quality Forum: Serious Reportable Events
• Vermont Statutes: Patient Safety Surveillance and Improvement System (18 V.S.A. Chapter 43A)

To report abuse, neglect or exploitation of a vulnerable adult or to enter a complaint against a facility or agency that provides health care, please contact the Division of Licensing and Protection:

Division of Licensing and Protection: Vermont Department of Disabilities, Aging & Independent Living

Phone: 800-564-1612 or 802-241-3918
Fax: 802-241-4092

REPORT ONLINE: Abuse Reporting Online Form

OR visit the Division of Licensing and Protection to access the online form and more information.

Five Steps to Safer Health Care: Patient Fact Sheet
What you can do to get safer health care.

20 Tips to Help Prevent Medical Errors
Be involved in your health care. Here's what you can do.

20 Tips to Help Prevent Medical Errors in Children
Be involved in your children's health care. Here's what you can do.

Vermont Program for Quality in Health Care, Inc.
802-229-2759

Vermont Department of Health
Margaret Robinson, Public Health Nursing Director
margaret.robinson@vermont.gov