Last year was a big year for hospital safety initiatives in Maryland. First, the Maryland Department of Health and Mental Hygiene (the Department) enacted regulations regarding hospital safety that went into effect on March 15, 2004. Additionally, the Delmarva Foundation and the Maryland Hospital Association launched the Maryland Patient Safety Center, a collaborative effort to study the causes of, and remedies for, unsafe hospital practices.
A. Safety Regulations
The safety regulations require each hospital to implement a patient safety program, and require each hospital governing board to review the effectiveness of its hospital's program.
The regulations also create requirements for adverse event and near-miss monitoring. The regulations specify what steps are to be taken in the event of what is described as a level 1, 2 or 3 adverse event, and what steps are to be taken in the event of a near miss.
A level 1 adverse event is an adverse event that results in death or serious disability. A level 2 adverse event is an adverse event that requires a medical intervention to prevent death or serious disability. A level 3 adverse event is an adverse event that does not result in death or serious disability, and does not require any medical intervention to prevent death or serious disability. Examples of a level 3 adverse event include, among other things, minor medication errors and minor falls. Finally, a near-miss is a situation that could have resulted in an adverse event but did not, either by chance or through timely intervention.
Hospitals must analyze the cause and effect of each adverse event or near miss. Such analysis will hopefully allow hospitals to implement procedures that lessen the likelihood of particular problems reoccurring.
Additionally, for each level 1 adverse event, the hospital must report the event to the Department within 5 days of learning of the event, and the hospital must submit its root cause analysis and action plan to the Department within 60 days of learning of the event.
Furthermore, if a hospital admits a patient with a condition resulting from an adverse event that may be related to care given to the patient at another Maryland hospital, the hospital must inform the appropriate medical review committee at the hospital where the adverse event allegedly occurred.
B. Maryland Safety Center
In addition to the Department's safety regulations going into effect last year, the Delmarva Foundation and the Maryland Hospital Association also established the Maryland Safety Center. The Center is a non-regulatory entity that is intended "to study the causes of unsafe practices and put practical improvements in place to prevent errors."
The Center serves as a data repository for hospital errors and near misses, which information is to be used by health care providers working with the Center to improve care. Reporting to the Center is done on a strictly confidential and entirely voluntary basis.
Expectations for the Maryland Safety Center are high. For example, one of the Center's first initiatives is to reduce ICU hospital death rates in Maryland by 30%.