Skip Navigation LinksAFL-09-11

State of Cal Logo

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

AFL 09-11
March 13, 2009

General Acute Care Hospitals
Acute Psychiatric Hospitals
Special Hospitals

Best Practices for Prevention of Adverse Events

​The California Department of Public Health (CDPH) is dedicated to optimizing the health and well-being of the people in California. As such, CDPH values new information and progressive solutions that provide greater protection for the people served in our

CDPH also recognizes and appreciates that hospitals often go to great lengths to prevent the occurrence of adverse events. Despite those efforts, during the period of July 1, 2007 through June 30, 2008, CDPH received more than 1,000 reports of incidents involving adverse events in California hospitals. CDPH believes that through the development of comprehensive policies and practices, hospitals can successfully reduce inadvertent risk to patient health and safety.

The department commends hospitals that have already committed themselves to the development of successful practices for their facility, in an effort to reduce and prevent adverse events. In support of those efforts, CDPH would like to invite hospitals to join the department in promoting successful prevention of adverse events statewide, through the sharing of best practice policies. Best practices would include policies and/or practices implemented to prevent the occurrence of adverse events that have been demonstrated to be successful.

This collaborative effort would allow hospitals to demonstrate their successful practices while providing the department quality examples to display statewide. Through such partnership, the hospital community can contribute to the mission of CDPH of achieving a safer environment for patients of California.

The department, therefore, cordially invites all hospitals that have successfully implemented best practices and/or policies for the prevention of adverse events, to submit, for display on the department’s website, samples of these proven policies.

Beneficial information to include:

  •  What policy or procedure (practice) has been implemented to prevent which
    adverse event(s)?
  • What method of measurement been implemented to determine the success of
    the practice? (How has the practice been proven effective?)

Hospitals’ participation in this venture is voluntary. For hospitals that are interested in participating, best practice documents may be submitted to:

Attention: Leslie Fullerton
P.O. Box 997377, MS 0512
Sacramento, CA 95899-7377

Or electronically to:

Additional information regarding the development of successful practices can be found on the Centers for Medical & Medicaid Services (CMS) website at:

Thank you for your considerate attention and ongoing dedication to the preservation of patient safety.



Original Signed by Kathleen Billingsley, R.N.

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

Page Last Updated :