Patient Safety, 2005

Maryland Health Care Commission

August 2005

A June 2001 Patient Safety Workshop sponsored by AHRQ's User Liaison Program (ULP) helped influence the development, culture, and focus of the Maryland Patient Safety Center, a unique, non-regulatory collaborative created by the Maryland Health Care Commission (MHCC). Jointly run and largely funded by the Maryland Hospital Association and the Delmarva Foundation, the Maryland Patient Safety Center develops and implements strategies and systems to improve safety through provider education and the voluntary reporting of adverse events and near misses.

"The AHRQ workshop presented some simple strategies regarding the culture of patient safety that didn't involve a major investment in information technology," says former MHCC Executive Director Barbara McLean, who managed the process to create the center. "The impact of that kind of information sharing, which can lead to immediate system change and improvements, was huge. The issue needed to be on the agenda of all health care facilities."

The ULP Workshop, "Beyond State Reporting: Medical Errors and Patient Safety Issues," included information on understanding the nature and severity of medical errors and their root causes from a systems perspective, as well as various approaches to reporting errors and adverse events. A number of states participated as teams representing the different groups that need to collaborate to improve patient safety—government, private sector purchasers, consumers, and providers (hospital and health system staff). The team approach led to some states, including Maryland, to continue to work on patient safety issues after the workshop.

MHCC's Maryland Patient Safety Center is part of a multi-pronged patient safety strategy that supplements the State's current regulatory and statutory requirements. Authorized legislatively by the Maryland General Assembly in 2003, the Center was established in June 2004.

Since opening, the Center sponsored its first annual Maryland Patient Safety Conference in March 2005, attracting 730 attendees, including representatives from 53 hospitals/health systems and 26 nursing homes. The Maryland Patient Safety Center concentrates on education and skills training, using the learning collaborative to change hospital safety cultures. It also collects adverse event and near-miss data to support system and process improvements.

Impact Case Study Identifier: OCKT 05-05
AHRQ-Sponsored Activity: User Liaison Program (ULP) Workshop
Topic(s): Patient Safety
Scope: Maryland

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