# COMAR Title 10 — Maryland Department of Health

## Subtitle 07 — Hospitals

### Chapter 06 — Hospital Patient Safety Program

#### Regulation .01 Purpose.

*COMAR 10.07.06.01*

The purpose of this chapter is to provide a safe environment for patients by requiring hospitals to:

A. Identify adverse events;

B. Encourage reporting of near-misses;

C. Assess and prioritize near-misses and adverse events based on level of disability or potential disability to patients;

D. Determine the appropriate hospital response based on level of disability or potential disability;

E. Conduct a root cause analysis of:

  (1) All level 1 events;

  (2) All level 2 events; and

  (3) If warranted, any near-miss or other adverse event;

F. Conduct an appropriate investigation of adverse events and near-misses that do not require or warrant a root cause analysis;

G. Provide a process by which the concerns of patients can be addressed; and

H. Provide a process to notify a patient or, if appropriate, a patient's family, whenever an outcome of care differs significantly from an anticipated outcome.