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Trenton, NJ 08625-0360

For Release:
December 17, 2008

Heather Howard

For Further Information Contact:
Marilyn Riley
(609) 984-7160

Third Annual Report Shows Patient Safety Reporting Increases



Hospital reporting of adverse patient safety events rose again in 2007 as New Jersey continued to build a culture of safety based on reporting, analyzing and correcting medical errors, Health and Senior Services Commission Heather Howard announced today. 


          Hospitals reported nearly 1,300 events from February 2005, when the Patient Safety Initiative began, through 2007 and worked with the Department to make comprehensive changes to prevent errors from recurring.  Through November 2008, hospitals have reported a total of 1,770 events.


The reported information is also used to issue special industry alerts identifying urgent problems with potential statewide impact.  Last year, the Department issued a special alert warning hospitals of the potential for confusing heparin, which prevents blood clotting, with insulin, which is used to treat diabetes.  When mistakenly given to a non-diabetic, insulin can cause dangerously low blood sugar.


“Not only is there more hospital reporting, hospitals are now much more skilled at analyzing their patient care systems when there is an error, and developing sophisticated solutions,” Commissioner Howard said.


“Over the last few years, the Department has collected a wealth of information on successful strategies hospitals have used.  We can now share those lessons learned with other hospitals and do it more effectively, because we know each hospital and its culture individually.” 


In 2007, the Department, the New Jersey Hospital Association and the health care industry also launched an initiative to standardize color-coded patient wrist bands across hospitals, long-term care facilities, home health agencies and emergency responders. Previously, colored-coded wrist bands had varied by facility and a nurse working part-time at two different facilities could inadvertently make a health-threatening error. A toolkit is available from NJHA to help facilities switch to the new system.


According to the third annual patient safety report, more hospitals are reporting more events than in previous years.  Seventy-five of 80 hospitals, or 94 percent, reported 456 patient safety events in 2007, compared with 88 percent of hospitals (71 of 81) reporting 450 events in 2006, and 83 percent (68 of 82) reporting 376 events in 2005.  The average number of events per hospital rose to 5.7 in 2007, up from 4.6 in 2005.


Falls and pressure ulcers continue to be the most frequently reported events.  In 2007, the percentage of falls increased, while the percentage of pressure ulcers declined by half.


Medicare has announced it will stop reimbursing hospitals for care related to in-hospital falls, and facilities may have increased their focus on fall prevention and detection as a result.   The decline in pressure ulcers may be a result of the 2006-2007 Pressure Ulcer Collaborative co-sponsored by the Department and the New Jersey Hospital Association.  The collaborative focused on patient care and pressure ulcer prevention.


As a consequence of an adverse event, patients were most likely to need additional laboratory testing, patient monitoring or diagnostic imagining; suffer physical disability or mental impairment; or to require a longer hospital stay.  Seventy-two patients died due to errors. 


The report notes that the number of events a hospital reports is not a good measure of its overall safety.  In some cases, a hospital may identify and report more errors because it is more vigilant about patient safety than a hospital that reports fewer. 


Under the Patient Safety Act, hospitals are required to report events such as surgical errors, medication errors, falls and pressure ulcers (bed sores) that meet certain criteria.  Hospitals must then conduct a thorough Root Cause Analysis to find the factors that led to each error, and develop solutions to the problem. The Department works with hospitals to make sure both the analysis and corrections are comprehensive. 


The Department has begun preliminary work on a new web-based patient safety reporting system for reporting errors and root cause analyses.  The new system should be online in 2010.


Patient Safety Initiative: 2007 Summary Report is available on the Department’s web site at:



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