Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 1
Subtitle 07 - HOSPITALS
Chapter 10.07.06 - Hospital Patient Safety Program
Section 10.07.06.03 - Patient Safety Program
Universal Citation: MD Code Reg 10.07.06.03
Current through Register Vol. 51, No. 19, September 20, 2024
A. General. On or before March 15, 2004, a hospital shall have in effect a patient safety program that meets the requirements of this chapter.
B. Duties of the Hospital.
(1) The hospital shall identify an individual
as patient safety coordinator who shall:
(a)
Coordinate patient safety activities;
(b) Facilitate assessment and determination
of the appropriate response to reported near-misses and adverse events related
to patient care;
(c) Monitor root
cause analyses and any actions resulting from a root cause analysis;
and
(d) Provide for flow of
information among quality assurance, credentialing, peer review, and any
patient safety committee.
(2) The hospital shall establish:
(a) Patient safety education programs for all
staff; and
(b) An internal staff
committee structure in accordance with Health Occupations Article, §1-401, Annotated
Code of Maryland to conduct a review and evaluation of patient safety
activities in accordance with this chapter.
(3) The governing board of a hospital shall
develop a process to review the hospital's patient safety program and to
determine the effectiveness of the hospital's patient safety program.
(4) Before a committee may operate or review
patient safety activities under this chapter, a hospital shall require that the
committee meet the requirements for a medical review committee under Health
Occupations Article, §1-401, Annotated
Code of Maryland.
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