Regulation .03 Patient Safety Program.
Regulation .03 Patient Safety Program.LinkCopy Citation
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.