Overview
In 2004, legislation was enacted that requires Maryland hospitals to report adverse events resulting in death or serious disability. The law also requires hospitals to perform a root cause analysis (RCA) for each event.
OHCQ's Maryland Hospital Patient Safety Program (MHPSP) reviews each event, determines whether an RCA is required, and maintains a database of RCA reports.
MHPSP is based on Maryland Health-General Code §19–304. The regulations for the program are found in COMAR 10.07.06.
Reporting an Adverse Event
Per Maryland Health-General Code §19–304, each event must be reported within five days of the hospital's knowledge of the occurrence. Please use this link to submit the initial event report:
Initial Report of an Adverse Event
Standardized Forms
OHCQ has created a Standard RCA Tool as well as targeted tools for hospital-acquired pressure injuries (HAPIs) and falls. Hospitals are strongly encouraged to use these tools.
OHCQ Standard RCA Tool
OHCQ Fall Short Form
OHCQ HAPI Short Form
Hospitals choosing to submit other forms are responsible for ensuring their documentation complies with the requirements of COMAR 10.07.06.
Event Reporting Requirements
Events leading to death or serious disability which are not related to the natural course of a patient's illness must be reported to OHCQ. In addition, all Joint Commission Sentinel Events or National Quality Forum Serious Reportable Events must be reported. Collectively, these are known as Level 1 Adverse Events.
The following decision tree provides guidance in determining whether an event qualifies as a Level 1 Adverse Event:
Adverse Event Reporting Decision Tree
Event Reclassification
If you previously reported a Level 1 Adverse Event and now believe it should be reclassified (e.g., further investigation has determined the event does not meet Level 1 Adverse Event criteria), please submit the following form:
Request to Change Classification of Event
Supplemental Materials
Adverse Event Reporting Categories
Online Initial Report and RCA Submission Guide
Maryland Hospital Patient Bill of Rights
