The Department shall do the following: (1) Analyze adverse event reports, corrective action plans, and findings of the root cause analyses to determine patterns of systemic failure in the health care system and successful methods to correct these failures. (2) Communicate to individual health care facilities the Department's conclusions, if any, regarding an adverse event reported by the health care facility. (3) Communicate to relevant health care facilities any recommendations for corrective action resulting from the Department's analysis of submissions from facilities. (4) Publish an annual report that does the following: (i) Describes, by institution, adverse health care events reported. (ii) Summarizes, in aggregate form, the corrective action plans and findings of root cause analyses submitted by health care facilities. (iii) Describes adopted recommendations for quality improvement practices. plans, and findings of the root cause analyses to determine patterns of systemic failure in the health care system and successful methods to correct these failures. the Department's conclusions, if any, regarding an adverse event reported by the health care facility. any recommendations for corrective action resulting from the Department's analysis of submissions from facilities. care events reported. corrective action plans and findings of root cause analyses submitted by health care facilities. quality improvement practices.
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