# COMAR Title 10 — Maryland Department of Health

## Subtitle 07 — Hospitals

### Chapter 06 — Hospital Patient Safety Program

#### Regulation .05 Procedures for Level 1 and 2 Adverse Events and Certain Near-Misses.

*COMAR 10.07.06.05*

A. When a level 1 or 2 adverse event, or a near-miss that warrants a root cause analysis occurs, the hospital shall:

  (1) Provide immediate care to the patient;

  (2) Identify any immediate corrective action to prevent reoccurrence;

  (3) Identify and report the event in accordance with the hospital's reporting process;

  (4) Complete a root cause analysis within 60 days of the time that the hospital has knowledge of the occurrence;

  (5) Develop and implement an action plan to correct any systems problems;

  (6) Share any pertinent information with quality assurance or other medical review committees; and

  (7) Aggregate data to determine patterns or trends.

B. All patient safety activities shall be conducted by a medical review committee established under Health Occupations Article, §1-401, Annotated Code of Maryland.