Reporting of Patient Deaths
SOTA and AB Responses (7)
24. Request posed during 9/19/07 SMA Quarterly Conference Call.
Please provide any material on the reporting of patient deaths, including data, analysis, blank forms, and expected reporting burden.
Louise Polansky, IN:
Here is a quick comment on death reporting which may be relevant only to Indiana. We just began requiring reporting of deaths to the SMA, and I got our first reports today from CRC Health. These reports are consistent with our experience with recent deaths in a couple of central and northern Indiana counties which were controversial.
What is becoming clear is that cause of death of OTP patients is very challenging to obtain in that if the death is referred to coroners' offices, the coroner may or may not cooperate (elected office), and if the report is obtained, it may take months before it's available. If the death isn't referred to a coroner, then cause is never attributed. What I'm saying is that getting information on cause of OTP patient death is not as easy as it is on "Bones" or any of those other CSI shows and not nearly as interesting.
Judith Stanley (NCCHC) Correctional Accreditation Body:
We have no information on any OTP linked deaths. We would not have that until we survey and get it retroactively.
Denise Clayborn, VA
There were 24 deaths in Virginia reported bythe OTPs during State Fiscal Year 2007.OTPs reportedeight deaths during Calendar Year 2007 to date. The causes of deaths varied and were not necessarily methadone related. Here is a copy of the Death and Incident form.
Joel Armstrong, FL
This is a link to the Florida Department of Law Enforcement's Medical Examiners 2006 report on Drugs Identified in Decease Persons. Also I copied and pasted the main Methadone Parts of the report (if that will make it a little handier).
http://www.fdle.state.fl.us/publications/Examiners/2006DrugReport.pdf
FLORIDA DEPARTMENT OF LAW ENFORCEMENT June 2007
2006 Report
2006 MEC Drug Report Page i
Data Collection
The Office of Vital Statistics reported more than 171,000 deaths occurred in Florida during 2006. Of these, the medical examiners reported on 7,741 drug related deaths (whether the cause of death or merely present) through toxicology reports submitted to the Medical Examiners Commission. This number is up from 7,573 cases reported in 2005. The vast majority of these 7,741 cases involved more than one drug listed in the report. The state’s medical examiners were asked to distinguish between the drugs being the “cause” of death or merely “present” in the body at the time of death.
Although there were deaths involving other drugs in Florida, data was collected on the following drugs for this report:
Benzodiazepines (Alprazolam, Diazepam, Flunitrazepam (Rohypnol), other Benzodiazepines);
Carisoprodol/Meprobamate;
Cocaine;
Ethyl Alcohol;
GHB;
Inhalants (Freon, Nitrous Oxide, other Inhalants);
Ketamine;
Methylated Amphetamines (Amphetamines, Methamphetamine, MDMA (Ecstasy), MDA, MDEA, other Methylated Amphetamines);
Opioids (Fentanyl, Heroin, Hydrocodone, Hydromorphone, Meperidine, Methadone, Morphine, Oxycodone, Propoxyphene, Tramadol, other Opioids);
Phencyclidine (PCP).
Questions regarding this report can be directed to Medical Examiners Commission Chairman, Stephen J. Nelson, M.A., M.D., or Commission staff.
Olin Dodson, NM (9/20)
We are beginning to address the finer points of the data work. Another meeting is scheduled for Wednesday. I will update you again after that.
Jim Bradshaw, OR
In Oregon we do not have any particular forms we would utilize to document patient deaths.
Rebecca Boss, RI
Attached you will find RI's reporting form. As you can see, it is not too burdensome and should not take providers long to complete.
We do ask providers to attach a more descriptive narrative - usually no longer than a paragraph or two. It should not take providers much longer than 10-15 minutes to complete both form and narrative. Usually, in the case of unexpected death, we will conduct an investigation that consists of chart review and staff interview. If there are findings, a report is sent with citations, requesting a plan of correction and perhaps further review of the incident by the program.
In calender year '06 we had 17 unexpected deaths reported by our OTPs In calender year '07 we had 14 unexpected deaths reported by our OTPs.
STATE OF RHODE ISLAND & PROVIDENCE PLANTATIONS
DIVISION OF BEHAVIORAL HEALTHCARE SERVICES
CONFIDENTIAL REPORT OF INCIDENT
Organization: ______Date and Time of Incident: ______
Mental Health ___ Group Home ___ CSP ___ GOP
___ Hospital Inpatient ___ Hospital Emergency Dept.
Substance Abuse ___ Detoxification ___ Residential ___ Outpatient
___ Opiate Treatment ___ Intensive OP ___ Women’s Day Treatment
Individual Involved: _____ Client _____ Staff _____ Visitor
Full Name and MHSIP ID/CIS #: ______
Diagnosis: ______DOB: ______
Location of Incident: (Include address): ______
Nature of Incident: (Mark "X") Entities Notified: (Mark "X")
1. _____ Unexpected Death 1. _____ Police - State/Local (Circle)
2. _____ Suicide 2. _____ Fire Department
3. _____ Suicide Attempt 3. _____ Rescue Squad (treatment related)
4. _____ Mistreatment 4. _____ Physician
5. _____ Assault/Battery 5. _____ Other (specify) _
7. _____ Client Neglect
6. _____ Client Abuse
8. _____ Serious Injury
9. _____ Serious Medication Error
10. _____ Serious Medication Reaction
11. _____ Missing/ Diverted Medication
12. _____ Environmental Emergency/Serious Equipment Failure
13. _____ Major Theft
14. _____ Fire
15. _____ Elopement
16. _____ Finding of Serious Staff Misconduct
17. _____ Other (specify)
Is follow-up necessary? ___ Yes ___ No
If “Yes”, is an investigation underway? ___ Yes ___ No
If “Yes”, anticipated date of completion: ______
Describe in a legible attachment the incident; initial findings; and preliminary actions taken. Include all pertinent data including the date on which the client last received services, provider name, the client’s mental/physical status at the time, and any risk assessment data collected as well as the type of services provided during the last 3-months of treatment.
______
Signature of Person Reporting Date Contact Phone #
______
Name Printed Title
Submit this form within 48 hours to: Chief Clerk, Division of Behavioral Healthcare
Send a copy to: The Office of Standards and Licensure
Address for all reports: MHRH, Barry Hall, 14 Harrington Road, Cranston, RI 02920
DBH/Lic1 Rev. 12/01/04
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