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

   1. (1) Provide immediate care to the patient;
   2. (2) Identify any immediate corrective action to prevent reoccurrence;
   3. (3) Identify and report the event in accordance with the hospital's reporting process;
   4. (4) Complete a root cause analysis within 60 days of the time that the hospital has knowledge of the occurrence;
   5. (5) Develop and implement an action plan to correct any systems problems;
   6. (6) Share any pertinent information with quality assurance or other medical review committees; and
   7. (7) Aggregate data to determine patterns or trends.
2. B. All patient safety activities shall be conducted by a medical review committee established 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)