Md. Code Regs. 10.07.06.06

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.07.06.06 - Root Cause Analysis

A. The hospital shall appoint an interdisciplinary root cause analysis team that shall include:

(1) Individuals who have knowledge of the event or near-miss;

(2) Representatives of hospital leadership; and

(3) Individuals with expertise in the subject matter of the event.

B. The root cause analysis team shall interview and permit participation of individuals who were directly involved in the event or near-miss and allow the individual to participate in the root cause analysis as appropriate.

C. The root cause analysis shall examine the cause and effect of the event through an impartial process by:

(1) Analysis of human and other factors;

(2) Analysis of related processes and systems;

(3) Analysis of underlying cause and effect systems through a series of "why" questions;

(4) Identification of risks and possible contributing factors; and

(5) Determination of improvement in processes or systems.

D. A root cause analysis shall:

(1) Be internally consistent; and

(2) Include consideration of relevant literature and best practices.

E. The hospital shall provide feedback including changes to hospital policy or procedure resulting from the root cause analysis to hospital employees and staff who were involved in the event or near-miss and to other employees or staff who would benefit from the feedback.

Md. Code Regs. 10.07.06.06