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Revised OMR Incident Management Bulletin To Be Issued
April 10, 2003

The Office of Mental Retardation (OMR) is completing a revision of the Incident Management Bulletin based on feedback from provider focus groups, county MH/MR programs, PCPA and others (including families and consumers), and on a review of HCSIS data. There was final discussion between OMR and providers about this draft at a meeting on April 2. The revised bulletin may be issued within the next month and there will be a 60-day comment period. OMR stated that comments will be considered before the final draft is completed in late summer or early fall.

The Incident Management Interpretive Guidelines published on October 29, 2002 and November 27, 2002 are incorporated into the planned draft bulletin. Also incorporated will be HCSIS procedures that did not exist when the original bulletin was released. Incident reporting will be simplified, with fewer screens to view and complete. Reporting of restraints, medication errors, and hospitalizations may require the use of only one screen. There will more emphasis on the use of check boxes as opposed to text screens.

An important part of focus group feedback was that incident reporting and investigation were not necessary for every medication error. While such errors are important and should be tracked, they are not generally incidents that require investigation. The new bulletin will not require county approval of every medication error report, but counties will review the errors and restraints at regular intervals. Optional fields about med errors will be available for providers' own risk management and data purposes. Some detailed information that was suggested for medication error reports was deleted, based on provider feedback, as bulletin drafts were developed. Also reconsidered was the inclusion of individual employee names in the medication error reports, which will not be required.

OMR utilized the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) and their Taxonomy of Medication Errors in the bulletin's development. This tool is apparently used by hospitals, physicians, and other health care providers. It can be accessed at www.nccmerp.org/sidebar.htm.

The draft revised Incident Management Bulletin will be sent to PCPA's MR providers for comments and reactions as soon as it is received.

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