Section 1279.6 Of Article 3. Regulations From California Health And Safety Code >> Division 2. >> Chapter 2. >> Article 3.
1279.6
. (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.