{"id":98,"date":"2023-08-30T15:20:30","date_gmt":"2023-08-30T22:20:30","guid":{"rendered":"https:\/\/www.cdcr.ca.gov\/hcdom\/?post_type=dom&#038;p=98"},"modified":"2026-10-12T13:07:31","modified_gmt":"2026-10-12T20:07:31","slug":"1-2-6-statewide-patient-safety-program1-2-6","status":"publish","type":"dom","link":"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-1-health-care-governance-and-administration\/article-2-health-care-program-governance\/1-2-6-statewide-patient-safety-program1-2-6\/","title":{"rendered":"1.2.6 Statewide Patient Safety Program"},"content":{"rendered":"\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Policy<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>California Correctional Health Care Services (CCHCS) shall maintain a Statewide Patient Safety Program to identify, prevent, and mitigate risk to patients, staff, and visitors, while improving health outcomes. This program shall include a program operations and management structure, surveillance systems such as health care incident reporting, established patient safety priorities, methods for problem analysis and performance improvement, and activities that promote a culture of learning and continuous improvement.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Procedure<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block is-style-default\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Statewide Health Care Incident Report Review<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Statewide Patient Safety Program shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Maintain a Statewide Patient Safety Committee (PSC) to provide oversight of the statewide program.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Maintain a comprehensive multidisciplinary process for identifying, reporting, and assessing health care incidents including sentinel events, in accordance with state law and the health care industry\u2019s best practices.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Maintain a surveillance system for the centralized collection and review of patient safety data.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Provide guidance on how to utilize the institution quality committee structure to oversee local operation of the Patient Safety Program.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Communicate and promote patient safety awareness through:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Patient safety stories and alerts.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Aggregate reporting of findings and recommendations from health care incidents or Root Cause Analyses (RCAs).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Recommendations to modify statewide policies and procedures.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Release reports and special studies which can include analysis of morbidity and mortality, health care incident reporting and RCA trends, and patient safety accomplishments to inform organizational priorities and initiatives.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Implement decision support tools (e.g., job aids, guides, forms, checklists, and flowcharts), and provide technical assistance, staff development and education programs to support Patient Safety Program implementation, RCAs, problem analysis, and process redesign.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Promote a patient safety culture that encourages staff to identify and report health care incidents, mitigate patient safety risks, and emphasize continuous learning and improvement.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Statewide Patient Safety Program shall identify program patient safety priorities on at least a triennial basis using system surveillance data, health care incident reporting trends, RCA findings and recommendations, and community and industry literature and best practices.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Statewide Health Care Incident Report Review<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Statewide health Care incident Review Committee (HCIRC), a subcommittee of the Statewide PSC, shall have oversight of the statewide Health Care Incident Reporting system and RCA process.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Regional Health Care Executive shall ensure staff conducts RCAs and implements associated Plans of Action and utilize the eHCIR System data and trends to identify and take action to mitigate patient safety risks within an individual institution or across a region.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Patient Safety Program shall conduct an initial review of all health care incidents reported to the eHCIR System to determine an appropriate disposition and ensure potential sentinel events or other anomalous health care incidents are referred for review by the Statewide HCIRC.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-default\">\n\t\t\t\t\t<p><strong>Statewide Patient Safety Committee<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The Statewide PSC, a subcommittee of the Statewide Quality Management Committee (QMC), shall have oversight of the Statewide Patient Safety Program.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Statewide PSC shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identify patient safety priorities triennially for statewide interventions and performance improvement as part of the Statewide Performance Improvement Plan.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Develop statewide training programs and decision support tools (e.g., toolkits, job aids, guides, forms, checklists, and flowcharts) to support patient safety culture, surveillance, health care incident reporting and review, RCAs, systems improvement, and process redesign.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Collaborate with various program areas to redesign health care processes to improve patient safety.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Coordinate patient safety activities with other committees and programs when appropriate including, but not limited to, the Statewide HCIRC, Headquarters Mortality Review, Systemwide Pharmacy and Therapeutics Committee, and Statewide QMC.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Issue statewide patient safety alerts for a health care incident or trend which reveals a problem that all\u00a0institutions should immediately address, or other critical patient safety concerns which require statewide\u00a0notification.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Support outreach and other activities to encourage reporting of health care incidents including near misses, medication events, and sentinel events.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Maintain an information system and process for submitting, referring, and evaluating reported health care incidents including, but not limited to:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>A centralized eHCIR System for identifying and reporting patient safety issues, near misses, sentinel events, and other anomalous health care incidents.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>An eHCIR Registry and Incident Summary accessible to select staff to ensure that institutions are informed of health care incident reports specific to their institution and patient care areas.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>A standardized process for the identification and examination of sentinel events using the RCA process and CCHCS RCA Tool Kit.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Maintain a Patient Safety Dashboard that aggregates eHCIR System data and provides health care incident reporting trends to identify patient safety improvement opportunities.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Establish and maintain a multidisciplinary Statewide HCIRC with headquarters level representation from all health care disciplines.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Promote an organizational culture of continuous learning and improvement.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Reports to the Statewide QMC and provides oversight to the Statewide HCIRC.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Membership, Quorum Requirements, and Meeting Frequency<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Statewide Patient Safety Officer, or designee, shall serve as chairperson of the Statewide PSC.\u00a0 The chairperson shall ensure that the Statewide PSC meets regularly, the committee agenda reflects the responsibilities described in this procedure, committee decisions are appropriately documented, and that each member of the committee has signed a confidentiality agreement.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The statewide program lead in Medical Services, Nursing Services, Pharmacy Services, Dental Services, the Mental Health Program, Corrections Services, and Health Care Policy and Administration shall select one headquarters designee to serve as a member on the Statewide PSC. The chairperson of the\u00a0Statewide\u00a0HCIRC and other program representatives may be asked to serve as members at the discretion of the Statewide PSC. CCHCS Office of Legal Affairs Chief Counsel, or designee, shall serve as a non-voting member, in an advisory capacity.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Each member has one vote, and a quorum exists when more than one-half of voting members are present. A quorum must be present to conduct a valid meeting and to protect the integrity of the decision-making process.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Presenters and observers may attend as appropriate if approved by the Statewide PSC Chairperson.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Statewide PSC shall meet at least quarterly or more often as necessary to carry out its responsibilities.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Electronic records of committee proceedings shall be kept in a secure location for ten years.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-default\">\n\t\t\t\t\t<p><strong>Statewide Health Care Incident Review Committee<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Statewide HCIRC shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Conduct reviews of health care incidents reported to the eHCIR System that are potential sentinel events and any other anomalous health care incidents to determine an appropriate disposition. \u00a0This may include elevating select health care incidents to appropriate statewide, regional, or institution program leadership for further review or follow-up.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Refer health care incidents with identified clinical practice concerns or potentially blameworthy acts or reckless behavior to the appropriate peer review or professional practice committee or hiring authority.<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Health care incidents assigned an RCA that includes a referral to peer review or the hiring authority, or a temporary redirection of staff from direct patient care, shall proceed without delay or deferral. The staff referred shall be excluded from the RCA process.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identify sentinel events and assign RCAs, which may include collaboration with regional and institution leadership to obtain additional information about the incident prior to assignment, and when appropriate, recommend grouping multiple similar incidents into an aggregate\u00a0RCA.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Coordinate with institutions to ensure RCAs are completed, approved, and submitted in accordance with Health Care Department Operations Manual, Section 1.2.7(b)(6) Root Cause Analysis.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Upon receipt and review of an RCA Report, communicate with the institution and regional leadership to provide feedback, including requesting revisions and clarification to the RCA Report if it does not meet requirements for a thorough and credible RCA.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Upon approval of the RCA Report, monitor progress of the RCA Plan of Action for at least four months. Communicate with the institution to obtain information or intervene, or elevate to regional leadership for additional support, if needed.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Provide oversight of institution self-assigned RCAs when requested.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Report out at least quarterly to the Statewide PSC with health care incident report and RCA data, trends, and recommendations.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Promote an organizational culture of continuous learning and improvement.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Reports to the Statewide PSC at least quarterly.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Committee Membership, Quorum Requirements, and Meeting Frequency<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The statewide program lead in Medical Services, Nursing Services, Pharmacy Services, Dental Services, and the Mental Health Program, including Psychiatry, shall select at least two headquarters designees to serve on the Statewide HCIRC. Corrections Services shall select at least one designee to serve as an ad hoc subject matter expert.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Statewide PSC shall select an HCIRC member to serve as chairperson. The chairperson shall ensure that the HCIRC meets regularly, the committee agenda reflects the responsibilities described in this procedure, committee decisions are appropriately\u00a0documented, and that each member of the committee has signed a confidentiality agreement.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Each member has one vote, and a quorum exists when at least three voting members from different disciplines are present.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The HCIRC shall meet as necessary, up to daily, to carry out its\u00a0responsibilities.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Electronic records of committee proceedings shall be kept in a secure location\u00a0for ten years.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-default\">\n\t\t\t\t\t<p><strong>Confidentiality &#8211; Protected Proceedings and Records<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The records of the committees and staff responsible for the evaluation and improvement of the quality of patient care shall be maintained as confidential and protected from discovery to the extent permitted by law.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>All California Department of Corrections (CDCR) and Rehabilitation and CCHCS staff shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Maintain confidentiality regarding patient safety records including, but not limited to, health care incident reports and documentation from health care incident reviews or the RCA process.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Refer all requests for patient safety records (e.g., health care incident reports, RCA reports) to the Statewide Patient Safety Program at m_PatientSafety@cdcr.ca.gov, for review and processing. Patient safety records may\u00a0not be released to any unauthorized person, organization, or stakeholder.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>References<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block is-style-default\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Health and Safety Code, Division 2, Chapter 2, Article 1, Section 1250<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Health and Safety Code, Division 2, Chapter 2, Article 3, Sections 1279, 1279.1, and 1279<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Code of Regulations, Title 22, Division 5, Chapter 12, Article 5, Section 79787, Reporting<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 3, Article 2, Health and Safety Program<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 5, Article 11, Section 51110.11, Written Reports<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Department of Corrections and Rehabilitation, Mental Health Services Delivery System Program Guide, Chapter 10, Suicide Prevention and Response<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.7, Institution Patient Safety Program<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.10, Mortality Review and Reporting<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.11, Pharmacy Quality Assurance Program<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Food and Drug Administration, MedWatch: The FDA Safety Information and Adverse Event Reporting Program (<a href=\"http:\/\/www.fda.gov\/safety\/medwatch\/default.htm\">http:\/\/www.fda.gov\/safety\/medwatch\/default.htm<\/a>)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>The Joint Commission https:\/\/www.jointcommission.org\/topics\/patient_safety.aspx<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>National Commission on Correctional Health Care 2018 Standards for Health Services in Prisons<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>National Coordinating Council for Medication Error Reporting and Prevention<br>(<a href=\"http:\/\/www.patientsafety.va.gov\/\">http:\/\/www.patientsafety.va.gov\/<\/a>)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>United States Department of Veterans Affairs &#8211; Veterans Affairs National Center for Patient Safety<br>(<a href=\"http:\/\/www.patientsafety.va.gov\/\">http:\/\/www.patientsafety.va.gov\/<\/a>)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Veterans Health Administration Vision 2020<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Department of Public Health Center for Health Care Quality<br>(<a href=\"https:\/\/www.cdph.ca.gov\/Programs\/CHCQ\/Pages\/CHCQHome.aspx\">https:\/\/www.cdph.ca.gov\/Programs\/CHCQ\/Pages\/CHCQHome.aspx<\/a>)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Policy Control<\/strong><br>Executive Sponsor:  Deputy Director, Quality Management<br>Effective:  11\/2012<br>Revised:  11\/2018, 10\/12\/2026<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t","protected":false},"parent":49,"template":"","class_list":["post-98","dom","type-dom","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>1.2.6 Statewide Patient Safety Program - Health Care Department Operations Manual (HCDOM)<\/title>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"1.2.6 Statewide Patient Safety Program - Health Care Department Operations Manual (HCDOM)\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-1-health-care-governance-and-administration\/article-2-health-care-program-governance\/1-2-6-statewide-patient-safety-program1-2-6\/\" \/>\n<meta property=\"og:site_name\" content=\"Health Care Department Operations Manual (HCDOM)\" \/>\n<meta property=\"article:modified_time\" content=\"2026-10-12T20:07:31+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-1-health-care-governance-and-administration\\\/article-2-health-care-program-governance\\\/1-2-6-statewide-patient-safety-program1-2-6\\\/\",\"url\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-1-health-care-governance-and-administration\\\/article-2-health-care-program-governance\\\/1-2-6-statewide-patient-safety-program1-2-6\\\/\",\"name\":\"1.2.6 Statewide Patient Safety Program - Health Care Department Operations Manual (HCDOM)\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/#website\"},\"datePublished\":\"2023-08-30T22:20:30+00:00\",\"dateModified\":\"2026-10-12T20:07:31+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-1-health-care-governance-and-administration\\\/article-2-health-care-program-governance\\\/1-2-6-statewide-patient-safety-program1-2-6\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-1-health-care-governance-and-administration\\\/article-2-health-care-program-governance\\\/1-2-6-statewide-patient-safety-program1-2-6\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-1-health-care-governance-and-administration\\\/article-2-health-care-program-governance\\\/1-2-6-statewide-patient-safety-program1-2-6\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"HCDOM\",\"item\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/\"},{\"@type\":\"ListItem\",\"position\":3,\"name\":\"Chapter 1 &#8211; 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