<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".03" citation="COMAR 10.07.06.03" title_num="10" subtitle_num="07" chapter_num="06" heading="Patient Safety Program.">
  <paragraph num="A.">
    <text>General. On or before March 15, 2004, a hospital shall have in effect a patient safety program that meets the requirements of this chapter.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Duties of the Hospital.</text>
    <paragraph num="(1)">
      <text>The hospital shall identify an individual as patient safety coordinator who shall:</text>
      <paragraph num="(a)">
        <text>Coordinate patient safety activities;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Facilitate assessment and determination of the appropriate response to reported near-misses and adverse events related to patient care;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Monitor root cause analyses and any actions resulting from a root cause analysis; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Provide for flow of information among quality assurance, credentialing, peer review, and any patient safety committee.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>The hospital shall establish:</text>
      <paragraph num="(a)">
        <text>Patient safety education programs for all staff; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>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.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>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.</text>
    </paragraph>
    <paragraph num="(4)">
      <text>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.</text>
    </paragraph>
  </paragraph>
</regulation>