Maryland Hospital Safety Program

Tool Kit

The tools section contains the regulatory language and tools hospitals can use to report and review adverse events, including short forms for pressure ulcers and falls, requests to downgrade events, an event reporting form, and a sample RCA evaluation.

Reports and Alerts

Information regarding trends, best practices, and lessons learned obtained from the review of reported events and root cause analyses are disseminated to hospitals and to the public via the
 Patient Safety Program’s Annual Report. The patient safety program also releases periodic Clinical Alerts and/or Clinical Observations on topics of interest. ​


Legislation (COMAR 10.07.06) enacted in 2004 requires mandatory hospital reporting of serious adverse events; those that cause death or serious injury, defined as a physical or mental impairment that substantially limits one or more of the major life activities of an individual and lasts more than seven days or is still present at the time of discharge. The Patient Safety Program reviews the events and the submitted root cause analyses and provides feedback to hospitals on individual reports. 


Anne Jones, RN, BSN, MA
Nursing Program Consultant
410-402-8090 (phone)
410-402-8167 (fax)​