Regulation .07 Procedures for Level 3 Adverse Events and Certain Near-Misses.

If the event is not a level 1 or 2 event or a near-miss that warrants a root cause analysis, the hospital shall conduct an evaluation of the event to determine any problem area and corrective action.

All events shall be aggregated by type and level to determine any patterns or trends.

The hospital is encouraged to evaluate and trend all near-misses to determine any system problems.

The hospital shall monitor the results and effectiveness of all action plans.