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Mandatory Reporting Improves Maryland Hospital Patient Safety

Ruzanna Harutyunyan's picture

A recently released report by the Department of Health and Mental Hygiene (DHMH) Office of Health Care Quality (OHCQ) shows continuing progress in the reporting of patient care and safety across Maryland. Under the 4-year-old Maryland Patient Safety Program, hospitals are required to report adverse events to the patients or their families. The most serious events resulting in death or disability must be reported to the OHCQ for investigation.

“Through comprehensive reporting and vigorous investigation our goal is to eliminate these incidents altogether,” said John Colmers, Secretary of the Department of Health and Mental Hygiene. “We’ve established one of the nation’s leading patient safety programs that requires accountability and mandates that hospitals address issues quickly to prevent a recurrence.”

The latest release is a summary of the data compiled as a result of the reporting of serious adverse events inside Maryland hospitals. In FY 2008, 182 deaths and serious injuries were reported by hospitals: 82 resulted from patient falls, 20 from delays in treatment, and 11 were actual or attempted suicides.

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“We’re making progress and these numbers show that with greater reporting we’ll have better results for patients,” said Wendy Kronmiller, OHCQ Director. “We are not where we want or need to be, but the track record of this effort shows we’re making Maryland hospitals safer and better.”

The OHCQ now requires Maryland hospitals to have patient safety programs that promote internal reporting of all near misses and adverse events, an analysis of the cause of serious adverse events and near misses, and the implementation of corrective action to prevent a recurrence. OHCQ may issue civil monetary penalties against hospitals that do not comply with reporting requirements.

The OHCQ has always investigated complaints received from citizens and advocates related to care in Maryland hospitals. However last year, only five of the 182 adverse events reported to OHCQ were also received as a complaint. Over its four-year history, the Patient Safety Program has enabled the OHCQ to review over 600 serious adverse events that would otherwise not be known or investigated through the regulatory complaint process.

The annual report and analysis of incidents helps the OHCQ uncover trends and patterns with periodic clinical alerts to hospitals and other stakeholders. The findings are also shared with the non-profit Maryland Patient Safety Center to assist in their educational efforts and prevent adverse events in the future.