Patient Safety Reporting Initiative, NJDHSS

View of Operating Room In 2004, the New Jersey Patient Safety Act (P.L. 2004, c9) was signed into law. The statute was designed to improve patient safety in hospitals and other health care facilities by establishing a medical error reporting system.

Rather than seeking to place blame, the system promotes comprehensive reporting of adverse patient events, systematic analysis of their causes, and creation of solutions that will improve health care quality and save lives.

This site is designed to help health care facilities develop strong patient safety programs and fulfill the law’s mandatory reporting requirements.

Helpful Links for Consumers about Patient Safety:

September Newsletter: Retained Foreign Objects During Vaginal Deliveries and Caesarian Sections.
A Newsletter on the frequency and potential causes of retained objects in patients in the Labor and Delivery unit. The newsletter also presents effective corrective actions and recommendations to reduce and eliminate these preventable adverse events.

The Patient Safety Initiative is pleased to provide Consensus Definitions for the RCA Form. This document provides definitions and examples for the codes on the RCA Form to help support your continual efforts to improve patient safety and to maintain consistency in reporting.

Patient Safety Liaison Contact Form for reporting adverse patient safety events.

Event: The patient developed anesthetic toxicity (tonic-clonic seizures) following injection of a local anesthetic mix (lidocaine with epinephrine and bupivicaine). The episode was successfully aborted with the use of a lipid emulsion in combination with established ACLS protocols.

Facility Strategy: In addition to storing the lipid emulsion in the Emergency carts, the facility is now also keeping it in the Pre-Op area with syringes for immediate administration. Before starting a block, the closet is unlocked, and the medication is checked for integrity and its expiration date. In addition, before the second syringe of local anesthetic, the patient is specifically asked about early symptoms of toxicity. Recent reports in the literature suggest that lipid emulsion is an effective treatment for local anesthetic toxicity.

Previous Prevention Strategies

Department of Health and Senior Services P. O. Box 360, Trenton, NJ 08625-0360 Phone: (609) 292-7837 Toll-free in NJ: 1-800-367-6543 Our Locations
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