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PO Box 360
Trenton, NJ 08625-0360
|Fred M. Jacobs, M.D., J.D.|
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“We’ve begun the hard work of creating a culture of safety in our health care facilities. It’s going to take time, but our ultimate goal is to improve patient safety and quality of care in
“Every lesson learned in one facility can help save a life in another, which is why it’s such a high priority for us to share information across the industry. I urge health professionals to come forward to report errors so we can work together on solutions,” he added.
Falls and pressure ulcers, also known as bed sores, were the most common adverse events, while surgery-related errors were the third leading cause. As a result of errors, patients required longer hospital stays, additional testing, and major surgery. Fifty-seven patients died.
In order to prevent a recurrence of the same errors, DHSS employs a process known as Root Cause Analysis (RCA). This procedure requires hospitals to search for any and all factors that contributed to an error and develop systematic solutions to fix the root of the problem. When RCAs are being completed, the department insists that hospitals search for all factors that contributed to the error and develop systematic solutions, rather than merely counseling or reprimanding individual doctors or nurses. If the DHSS feels that an RCA is inadequate they have the authority to require the hospital to improve it and resubmit it until it is deemed acceptable.
For example, in one instance, a patient died after failing to receive an ordered echocardiogram to evaluate his heart. The test had been ordered through the hospital’s computerized system, but for the wrong patient. Coincidentally, the second patient had also been ordered to receive an echocardiogram. As a solution, the hospital built additional verification steps into the computer order screen and developed methods to identify when duplicate orders are valid.
DHSS shares findings with the industry through a newsletter, a web site and training sessions. Because all reporting is confidential, individual heath care facilities are never identified. The department has conducted a series of workshops for hospitals to learn more about nationally recognized practices to prevent falls and to develop their own programs. DHSS has featured falls prevention in its patient safety newsletter, which has also published case studies on diagnostic imaging errors and other issues.
The Patient Safety Act requires health care facilities to report all serious preventable adverse events that result in death, disability, or loss of body part or bodily function for more than seven days or present at discharge. DHSS is now developing detailed reporting regulations to implement the law. Those rules are expected to be proposed for public comment in the fall.
Under the new rules, DHSS will require data reporting on errors involving single-use medical devices. These are devices that have been approved for single use, but may be reprocessed and reused according to U.S. Food and Drug Administration guidelines. DHSS is collecting data in order to determine if reprocessed devices pose any patient safety issues.
After the rules are adopted, the department will begin expanding mandatory reporting to include special, psychiatric and rehabilitation hospitals; ambulatory care centers, home health care and hospices; and assisted living and long-term care facilities.
DHSS will also ultimately develop an anonymous, voluntary system for reporting “near misses” that don’t qualify for mandatory reporting.
According to the 2005 report, patient falls and pressure ulcers accounted for 54 percent of the 376 reports submitted. Surgical errors – such as foreign objects left in patients following surgery -- were involved in 17 percent. Another 14 percent related to other care management, including errors related to diagnostic imaging studies. Equipment failures were cited in five percent of reports, and medication errors in three percent.
These events had a serious impact on patients, the report noted. The most frequent consequences were longer hospital stays, additional patient monitoring, additional diagnostic and laboratory tests, major surgery, and physical or mental impairment.
According to the report, communication problems among hospital staff are the most common underlying cause of medical errors, cited in more than 60 percent of reports. Other leading issues are problems with care planning, patient assessment, staff orientation and training and patient observation.
Under the law, each health care facility is required to improve safety through a patient safety committee. The committee is responsible for reporting serious errors, and for analyzing and correcting their underlying cause. The committee also develops a safety plan for the facility and tracks error trends. Confidentiality of the patient safety committee’s work is also protected under the law.
The 2005 annual report is available on the department’s web site at http://www.state.nj.us/health/hcqo/ps/documents/2005_summary_report.pdf. Patient safety information is also available on the DHSS Patient Safety Initiative web page at http://nj.gov/health/hcqo/ps/index.shtml.
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Department of Health
P. O. Box 360, Trenton, NJ 08625-0360