New York Consolidated Laws, Public Health Law - PBH § 2805-j. Medical, dental and podiatric malpractice prevention program
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1. Every hospital shall maintain a coordinated program for the identification and prevention of medical, dental and podiatric malpractice. Such program shall include at least the following:
(a) The establishment of a quality assurance committee with the responsibility to review the services rendered in the hospital in order to improve the quality of medical, dental and podiatric care of patients and to prevent medical, dental and podiatric malpractice. Such committee shall oversee and coordinate the medical, dental and podiatric malpractice prevention program and shall insure that information gathered pursuant to the program is utilized to review and to revise hospital policies and procedures. At least one member of the committee shall be a member of the governing board of the hospital who is not otherwise affiliated with the hospital in an employment or contractual capacity;
(b) A medical, dental and podiatric staff privileges sanction procedure through which credentials, physical and mental capacity and competence in delivering health care services are periodically reviewed, and reviewed as otherwise warranted in specific instances and circumstances, as part of an evaluation of staff privileges;
(c) The periodic review and the review as otherwise warranted in specific instances and circumstances of the credentials, physical and mental capacity and competence in delivering health care services of all persons who are employed or associated with the hospital;
(d) A procedure for the prompt resolution of grievances by patients or their representatives related to accidents, injuries, treatment and other events that may result in claims of medical, dental or podiatric malpractice;
(e) The maintenance and continuous collection of information concerning the hospital's experience with negative health care outcomes and incidents injurious to patients, patient grievances, professional liability premiums, settlements, awards, costs incurred by the hospital for patient injury prevention and safety improvement activities;
(f) The maintenance of relevant and appropriate information gathered pursuant to paragraphs (a) through (e) of this subdivision concerning individual physicians, dentists and podiatrists within the physician's, dentist's or podiatrist's personnel or credential file maintained by the hospital;
(g) Education programs dealing with patient safety, injury prevention, staff responsibility to report professional misconduct, the legal aspects of patient care, improved communication with patients and causes of malpractice claims for staff personnel engaged in patient care activities;
(h) Continuing education programs for medical, dental and podiatric staff in their areas of specialty; and
(j) For the purposes of this section, the term “hospital” shall have the same meaning as is set forth in subdivision ten of section twenty-eight hundred one of this article.
2. Any person who, in good faith and without malice, provides information to further the purposes of the medical, dental and podiatric malpractice prevention program or who, in good faith and without malice, participates on the quality assurance committee shall not be subject to an action for civil damages or other relief as a result of such activity. Any hospital, or any person acting on behalf of such hospital, who, in good faith and without malice, takes or fails to take any action as a result of a review conducted pursuant to paragraph (b) or (c) of subdivision one of this section, shall not be subject to an action for civil damages or other monetary relief as a result of such action or failure to act, provided, however, that nothing in this subdivision shall relieve any hospital of any liability in an action for medical, dental or podiatric malpractice based on an act or failure to act as a result of a review conducted pursuant to paragraph (b) or (c) of subdivision one of this section, and provided further that nothing herein shall affect the authority of the commissioner pursuant to this chapter.
3. The commissioner shall make, adopt, promulgate and enforce such rules and regulations as he may deem appropriate to effectuate the purposes of this section.
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