In 2004, legislation was enacted that requires hospitals to report serious adverse events that cause death or serious injury. Serious injury is 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. OHCQ's Maryland Hospital Patient Safety Program reviews each event and provides feedback to the hospital on their root cause analysis. The regulations for the program are found in COMAR 10.07.06.
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 Clinical Alerts
Information regarding trends, best practices, and lessons learned from the review of reported events and root cause analyses is included in the annual Maryland Hospital Patient Safety Program Report. The program also issues periodic Clinical Alerts and Clinical Observations on topics of interest.
Hospitals submit encrypted reports and RCAs to firstname.lastname@example.org
Maryland Hospital Safety Program
Tennile Ramsay, MS, RN, CNL, CPPS
Nursing Program Consultant