1. A. General. On or before March 15, 2004, a hospital shall have in effect a patient safety program that meets the requirements of this chapter.

2. B. Duties of the Hospital.

   1. (1) The hospital shall identify an individual as patient safety coordinator who shall:

      1. (a) Coordinate patient safety activities;
      2. (b) Facilitate assessment and determination of the appropriate response to reported near-misses and adverse events related to patient care;
      3. (c) Monitor root cause analyses and any actions resulting from a root cause analysis; and
      4. (d) Provide for flow of information among quality assurance, credentialing, peer review, and any patient safety committee.

   2. (2) The hospital shall establish:

      1. (a) Patient safety education programs for all staff; and
      2. (b) 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.
   3. (3) 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.
   4. (4) 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.

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)