The purpose of this chapter is to provide a safe environment for patients by requiring hospitals to:

1. A. Identify adverse events;
2. B. Encourage reporting of near-misses;
3. C. Assess and prioritize near-misses and adverse events based on level of disability or potential disability to patients;
4. D. Determine the appropriate hospital response based on level of disability or potential disability;

5. E. Conduct a root cause analysis of:

   1. (1) All level 1 events;
   2. (2) All level 2 events; and
   3. (3) If warranted, any near-miss or other adverse event;
6. F. Conduct an appropriate investigation of adverse events and near-misses that do not require or warrant a root cause analysis;
7. G. Provide a process by which the concerns of patients can be addressed; and
8. H. Provide a process to notify a patient or, if appropriate, a patient's family, whenever an outcome of care differs significantly from an anticipated outcome.

Authority: Health-General Article, §§19-308 and 19-319, Annotated Code of Maryland

Effective date: March 15, 2004 (31:5 Md. R. 448)

Regulation .15B amended effective February 26, 2018 (45:4 Md. R. 206)

Regulation .17 adopted effective February 26, 2018 (45:4 Md. R. 206)