# COMAR Title 10 — Maryland Department of Health

## Subtitle 34 — Board of Pharmacy

### Chapter 35 — Infusion Pharmacy Services in an Alternate Site Care Environment

#### Regulation .08 Performance Improvement Program.

*COMAR 10.34.35.08*

A. The performance improvement program shall consist of:

  (1) A committee which:

    (a) Consists of representation of personnel and varied areas of job responsibility; and

    (b) Is responsible for analysis of data, reporting trends and corrective actions; and

    (c) Meets at least quarterly;

  (2) Quality assurance and performance improvement monitoring parameters;

  (3) Documentation requirements for:

    (a) Established monitoring parameters;

    (b) Trend analyses; and

    (c) Retention of committee meeting minutes for 3 years;

  (4) Documentation of tracking, trending, analyzing, resolving, and developing corrective action plans as appropriate for:

    (a) Medication errors;

    (b) Adverse drug reactions; and

    (c) Equipment malfunctions;

  (5) Reporting of adverse events to regulatory and standard-setting bodies as applicable to State and federal regulations;

  (6) Documentation and resolution of patient care issues involving:

    (a) Incorrect equipment, supplies, or medications;

    (b) Delays in delivery of care;

    (c) Missed doses;

    (d) Patient infections;

    (e) Failures in after-hours care; and

    (f) Patient, caregiver, or health care provider complaints;

  (7) Documentation of patient outcomes;

  (8) Recall management;

  (9) Patient compliance monitoring; and

  (10) Staff training and competency compliance.

B. The permit holder shall review the performance improvement program at a minimum of every 3 years.