Office of Health Care Quality Releases 2010 Maryland Patient Safety Report

Continued Improvement in Reporting of Adverse Events

Department of Health & Mental Hygiene News Release

Baltimore, MD (June 2, 2011) - The Maryland Department of Health and Mental Hygiene (DHMH) Office of Health Care Quality (OHCQ) has released its annual report on patient care and safety in Maryland hospitals. The report shows continued progress in the reporting of adverse events related to patient care and safety. Under the 6-year-old Maryland Patient Safety Program, hospitals are required to report adverse events that affect patients or their families. The most serious events resulting in death or disability must be reported to the OHCQ for investigation. 

 "We recognize Maryland hospitals' continued efforts to improve patient safety in their facilities", said Nancy Grimm, Director for the Office of Health Care Quality. "Increased reporting by hospitals is an indication of engaged and proactive patient safety programs, which ultimately promotes positive patient safety outcomes. The greater the reporting, the better results for patients."  

The latest report is a summary of the data compiled as a result of the reporting of serious adverse events inside Maryland hospitals. In FY 2010, 265 deaths and serious injuries were reported by hospitals: 88 resulted from patient falls; 59 from hospital acquired pressure ulcers; 20 from delays in treatment, and 15 from retained foreign bodies after a surgical procedure.  

The OHCQ 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.  

"Hospitals that regularly review errors, near-misses and misadventures are empowered to identify system failures and tend take definitive action to prevent their reoccurrence," added Director Grimm. "However, we believe there is always work to be done to improve efforts and we encourage hospitals to continue their mission to make their facilities safer for patients."  

The OHCQ has investigated 485 complaints received from citizens and advocates related to care in Maryland hospitals. However last year, only seven of the 265 adverse events reported to OHCQ were also received as a complaint. Over its six-year history, the Patient Safety Program has enabled the OHCQ to review over 1091 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.  

The FY 2010 Maryland Patient Safety Program report and the Clinical Alerts are available on the Office of Health Care Quality website at: .