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State of California—Health and Human Services Agency
California Department of Public Health

AFL 09-01
December 30, 2008

Acute Psychiatric Hospitals
General Acute Care Hospitals
Skilled Nursing Facilities
Special Hospitals

Patient Safety Plans and Tube Connection Restrictions

AUTHORITY:     Senate Bill (SB) 158 (Florez, Chapter 294, Statutes of 2008); (Health and Safety Code Sections 1279.6 and 1279.7)

This letter notifies you of legislation taking effect on January 1, 2009. SB 158 requires general acute care hospitals (GACHs), acute psychiatric hospitals (APHs), special hospitals (SHs) and skilled nursing facilities (SNFs) to establish patient safety plans (HSC § 1279.6) and hand hygiene programs (HSC § 1279.7) to improve patient safety and reduce patient suffering resulting from preventable events.

SB 158 requires GACHs, APHs, SNFs and SHs to establish patient safety plans for their facility. Each patient safety plan shall, at a minimum, establish:

  • A patient safety committee.
  • A reporting system for patient safety events.
  • A process for facility staff to conduct thorough analyses including but not limited to, root cause analyses, on reported patient safety events.
  • A reporting process that supports and encourages a culture of safety and reporting patient safety events.
  • A process for providing ongoing patient safety training for facility personnel and health care practitioners.
  • A definition of a patient safety event, which shall include, but not be limited to, all adverse events or potential adverse events that are determined to be preventable and health-care-associated infections, as defined by the National Healthcare Safety Network or the Healthcare Associated Infection Advisory Committee (HAI-AC), that are determined to be preventable.

The responsibilities of the patient safety committee shall include:

  • Review and approval of the patient safety plan.
  • Receive and review reports of patient safety events.
  • Monitor implementation of corrective actions for patient safety events.
  • Make recommendations to eliminate future patient safety events.
  • Review and revise patient safety plans, yearly or more often if necessary.

Additionally, beginning January 1, 2011, the use of any intravenous connection, epidural connection or enteral feeding connection for any purpose other than its intended purpose would be prohibited as a result of this bill, except in emergent or urgent situations.

The information in this AFL is a brief summary of SB 158 regarding patient safety plans and tube connection restrictions. Facilities are responsible for following all applicable laws. CDPH’s failure to expressly notify facilities of legislative changes does not relieve facilities of their responsibility for following all laws and for being aware of all legislative changes. Facilities should refer to the full text of SB 158 to ensure compliance.

A subsequent AFL discussing SB 158’s provisions concerning the expansion of responsibilities of existing HAI-AC functions will be distributed.

If you have questions regarding this issue, please contact your local district office.



Original Signed by Kathleen Billingsley, R.N.

Kathleen Billingsley, R.N.
Deputy Director
Center for Health Care Quality



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