(a) A health facility, as defined in subdivision (a), (b), (c), or (f) of Section 1250, shall develop, implement, and comply with a patient safety plan for the purpose of improving the health and safety of patients and reducing preventable patient safety events. The patient safety plan shall be developed by the facility, in consultation with the facility’s various health care professionals.
(b) The patient safety plan required pursuant to subdivision (a) shall, at a minimum, provide for the establishment of all of the following:
(1) A patient safety committee or equivalent committee in composition and function. The committee shall be composed of the facility’s various health care professionals, including, but not limited to, physicians, nurses, pharmacists, and administrators. The committee shall do all of the following:
(A) Review and approve the patient safety plan.
(B) Receive and review reports of patient safety events as defined in subdivision (c).
(C) Monitor implementation of corrective actions for patient safety events.
(D) Make recommendations to eliminate future patient safety events.
(E) Review and revise the patient safety plan, at least once a year, but more often if necessary, to evaluate and update the plan, and to incorporate advancements in patient safety practices.
(2) A reporting system for patient safety events that allows anyone involved, including, but not limited to, health care practitioners, facility employees, patients, and visitors, to make a report of a patient safety event to the health facility.
(3) A process for a team of facility staff to conduct analyses, including, but not limited to, root cause analyses of patient safety events. The team shall be composed of the facility’s various categories of health care professionals, with the appropriate competencies to conduct the required analyses.
(4) A reporting process that supports and encourages a culture of safety and reporting patient safety events.
(5) A process for providing ongoing patient safety training for facility personnel and health care practitioners.
(c) For the purposes of this section, patient safety events shall be defined by the patient safety plan and shall include, but not be limited to, all adverse events or potential adverse events as described in Section 1279.1 that are determined to be preventable, and health-care-associated infections (HAI), as defined in the federal Centers for Disease Control and Prevention’s National Healthcare Safety Network, or its successor, unless the department accepts the recommendation of the Healthcare Associated Infection Advisory Committee, or its successor, that are determined to be preventable.
(Added by Stats. 2008, Ch. 294, Sec. 2. Effective January 1, 2009.)
Last modified: October 25, 2018