Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 1
Subtitle 07 - HOSPITALS
Chapter 10.07.06 - Hospital Patient Safety Program
Section 10.07.06.14 - Documentation
Universal Citation: MD Code Reg 10.07.06.14
Current through Register Vol. 51, No. 19, September 20, 2024
A. On or before March 15, 2004, the hospital shall send to the Secretary a written description of its patient safety program that includes:
(1) The name of the patient safety
coordinator;
(2) The board policy
statement relevant to patient safety activities including the process to review
the hospital's patient safety program and to determine the effectiveness of the
hospital's patient safety program;
(3) A description of the near-miss and
adverse event identification and reporting process;
(4) A list of examples of adverse events that
shall be reported;
(5) A
description of the process for determining which near-misses warrant a root
cause analysis to be conducted;
(6)
A description of the near-miss and adverse event review, prioritization,
evaluation, and root cause analysis process;
(7) A description of the process used to
provide notification to a patient, and, if appropriate, to a patient's family
whenever an outcome of care differs from an anticipated outcome; and
(8) A description of the formal written
patient complaint process.
B. The hospital shall notify the Secretary of any change in its patient safety program related to the description required by this regulation within 30 days of the effective date of the change.
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