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The Department of Health and Mental Hygiene

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DHMH Press Releases : Progress in Hospital Reporting



Baltimore, MD (May 23, 2012) - The Maryland Department of Health and Mental Hygiene (DHMH) Office of Health Care Quality (OHCQ) has released its annual report on patient safety ( in Maryland hospitals. The report shows continued progress in the reporting of adverse patient outcomes. Under the seven year-old Maryland Patient Safety Program, hospitals are required to report adverse events that affect patients. 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 OHCQ. "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.  Leadership commitment also continues to be a critical element in ensuring a successful hospital patient safety program."
The latest report is a summary of the data compiled because of the reporting of serious adverse events by Maryland hospitals.  A total of 348 deaths and serious injuries were reported by hospitals in FY 2011.  Since the inception of the program in 2004 and through FY 2010, events related to Falls had been the most frequently reported Level 1 Adverse Event.  However, in FY 2011, the most commonly reported event category was  Hospital Acquired Pressure Ulcers, which is a shift from the number two position the previous year. 
In FY 2011, the number of Pressure Ulcers reported increased from 59 to 144 incidents.  DHMH is pleased that hospitals are recognizing this serious condition and have implemented evidence based best practices in an effort to decrease the occurrence of these debilitating events.   Retained Foreign Bodies after a surgical procedure ranked third in the number of events reported to the agency this fiscal year despite guidance from The Joint Commission and OHQC in encouraging hospitals to develop sustainable measures and protocols to avoid the problem. 
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 or other sanctions 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 to take definitive action to prevent their reoccurrence," added Director Grimm. "Although the hospitals have demonstrated a willingness to report serious events to DHMH, we believe many hospitals require improvement as to their internal reporting processes.  All hospitals must continue to self-monitor their patient safety activities in an effort to improve the quality of care for all patients."
The OHCQ has investigated 431 complaints received from citizens and advocates related to care in Maryland hospitals. However, last year, only two of the 348 adverse events reported to OHCQ were also received as complaints. Over its seven year history, the Patient Safety Program has enabled the OHCQ to review the corrective actions of 1439 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 discover 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 2011 Maryland Patient Safety Program ( annual report and the Clinical Alerts are available on the Office of Health Care Quality website at
Or click to directly access the report site.