(a) The Department shall maintain a Statewide Patient Safety Program to identify and improve problematic health care processes in conjunction with the statewide Quality Management Program.
(b) The Statewide Patient Safety Program shall encompass:
(1) Patient safety priorities that are reviewed and revised biennially to identify program objectives for statewide interventions and performance improvement activities.
(2) A comprehensive multidisciplinary health care incident reporting and review process for identifying, reporting, and assessing health care incidents including sentinel events.
(3) A committee structure at headquarters to provide oversight to the Statewide Patient Safety Program, review patient safety reports and data, and take action to mitigate patient safety risks and prevent adverse patient outcomes.
(4) A committee structure at each institution that oversees the local implementation of the Patient Safety Program by reviewing patient safety reports and data at the individual institution or care team level.
(5) Regular communication in the form of patient safety alerts, aggregate reporting of findings, and recommendations related to health care incidents or Root Cause Analyses (RCA).
(6) Technical assistance, decision support tools, and staff development and education programs to support problem analysis, RCA, and process redesign.
(7) A patient safety culture that encourages staff to proactively identify and report health care incidents.
(c) Department staff who observe or discover a health care incident, regardless of severity or absence of harm to a patient, shall report the incident using the centralized electronic Health Care Incident Reporting system within 24 hours of occurrence or discovery.
Credits
Note: Authority cited: Section 5058, Penal Code. Reference: Section 1279.1, Health and Safety Code; Section 5054, Penal Code; and Plata v. Newsom (No. C01-1351 JST), U.S. District Court, Northern District of California.
1. New section filed 7-1-2019 as an emergency; operative 7-1-2019 (Register 2019, No. 27). Pursuant to Penal Code section 5058.3, a Certificate of Compliance must be transmitted to OAL by 12-9-2019 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 12-5-2019 as an emergency; operative 12-10-2019 (Register 2019, No. 49). Pursuant to Penal Code section 5058.3, a Certificate of Compliance must be transmitted to OAL by 3-9-2020 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 3-9-2020 as an emergency; operative 3-10-2020 (Register 2020, No. 11). A Certificate of Compliance must be transmitted to OAL by 6-8-2020 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 3-9-2020 order transmitted to OAL 6-8-2020 and filed 7-20-2020 (Register 2020, No. 30).
This database is current through 4/19/24 Register 2024, No. 16.
Cal. Admin. Code tit. 15, § 3999.111, 15 CA ADC § 3999.111
