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In the first two years of New Jersey’s Patient Safety Initiative, hospitals worked with the Department of Health and Senior Services to analyze more than 800 serious patient safety events and make comprehensive changes to prevent such errors from recurring, Health and Senior Services Commissioner Heather Howard, J.D., announced today.
Nearly all hospitals reported adverse events in 2005 or 2006, and conducted a thorough Root Cause Analysis (RCA) to find the factors leading to each error, according to Patient Safety Initiative: 2006 Summary Report, the second annual program report.
“Patients have a right to expect safe, high-quality care,” Commissioner Howard said. “When a hospital steps forward to report an error, it helps make care safer for its own patients and for patients statewide. We are committed to collaborating with hospitals to create a safer environment for patients.”
According to the second annual report, hospital participation in the Initiative grew in the program’s second year. In 2006, 88 percent, or 71, of the state’s hospitals reported events – such as falls or surgical errors – compared with 83 percent (68 hospitals) in 2005. Hospitals also reported and analyzed more errors – 450 in 2006 compared with 376 the year before. The confidential reporting system began February 1, 2005.
The report noted that the number of events a hospital reports is not an absolute measure of its overall quality. A larger number of reports may reflect a hospital’s strong focus on patient safety and commitment to finding solutions when events occur.
The most common adverse events continued to be falls and pressure ulcers, also known as bed sores, followed by surgical errors. These events resulted in patients needing longer hospital stays, more tests, or additional monitoring by staff, among other complications. Forty-two patients died.
When an error is reported, the Department requires that the hospital perform a Root Cause Analysis. Hospitals must identify the problem’s root causes and develop systematic solutions to correct the problem. DHSS has the authority to require a more comprehensive analysis or set of solutions from hospitals, if warranted.
The Department uses information gained through this system to give the hospital industry important feedback. In addition, the Department has provided consumer-oriented information on its website and is in the process of increasing such information to help families of patients.
DHSS issues a periodic Patient Safety Newsletter as well as special industry alerts identifying urgent problems with potential statewide impact.
For example, a May 2006 alert asked hospitals to check the sandbags they use to immobilize part of a patient’s body or place pressure on an incision. The alert described how one patient was sent for an MRI with a bag labeled as a sandbag placed on an incision. However, the bag contained metal shot, which caused it to move toward the patient’s head in the presence of the MRI machine’s powerful magnet. Upon checking, other hospitals found similar “sandbags” and took corrective action. There were no serious injuries at any of the hospitals.
Three newsletters were published in 2006 focusing on: falls, including risk factors and prevention strategies; errors occurring during the diagnostic imaging process, including communicating the patient’s results; and surgery-related objects unintentionally left in the patient. Newsletters and alerts are included in the annual report and are posted on the web at http://nj.gov/health/ps/newsletter.shtml.
“These newsletters are a great resource. They offer specific information on the steps hospitals can take to find an error’s causes and prevent its recurrence,” the Commissioner said. “We ask all hospitals to use these newsletters in their internal discussions on patient safety.”
At the request of hospitals, the Department developed a workshop on falls that was offered three times in 2005 and 2006. Fifty-one hospitals created and launched their own falls reduction project, participated in periodic conference calls, and then met again with the group to present their results.
Pressure ulcers were the focus of a recent initiative of the New Jersey Hospital Association’s Quality Institute. The Pressure Ulcer Collaborative allowed hospitals to work with leading experts and with each other on issues relating to patient care and prevention.
Possibly because of increased awareness and improved hospital reporting, the number of reported falls and pressure ulcers increased in 2006 and they accounted for a greater share of the total than in 2005. Surgery-related adverse events declined over the two years. Few medication errors were reported in either year.
The top three causes of system failure leading to an adverse event were: communication among hospital staff, the patient care planning process, and staff orientation and training, according to the report.
Under the patient safety law, hospitals are required to report serious preventable adverse events that meet certain criteria.
For example, pressure ulcers are reportable when they meet a certain level of severity. Falls must be reported if they are linked to patient death, loss of a body part, disability, or loss of bodily function lasting more than seven days or still present when the patient is discharged. Surgery-related events include surgery on the wrong person or the wrong body part, and coma occurring during or after surgery, among others events.
Later this month, the proposed patient safety reporting regulations will be considered for final adoption by the Health Care Administration Board. If approved, they will take effect when published in the New Jersey Register.
Patient Safety Initiative: 2006 Summary Report is available on the DHSS web site at: http://www.state.nj.us/health/ps/documents/ps_report_2006.pdf.
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Department of Health
P. O. Box 360, Trenton, NJ 08625-0360