# COMAR Title 10 — Maryland Department of Health

## Subtitle 07 — Hospitals

### Chapter 06 — Hospital Patient Safety Program

#### Regulation .03 Patient Safety Program.

*COMAR 10.07.06.03*

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.