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  Patient Safety Initiative

View of Operating RoomIn 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.

New and Noteworthy

February Alert: Potential Errors Associated with Radiation Therapy.

Recently there has been extensive news coverage about overexposure to radiation during CT scans and linear accelerators (LINAC).  This Alert is to bring attention to this potentially serious patient safety concern.

Event: Failure to clarify the site of entry of the angioplasty in a busy Cardiac Cath Lab led to an attempted peripheral artery angioplasty on the wrong side.

Facility Strategy: The staff could not distinguish if “site” referred to the site of entry or the site of the angioplasty.  Re-education was necessary to address the misconceptions about laterality in the newer procedures being performed.  Multiple channels of communication between the physician’s office and the lab had to be standardized, including the various forms used.  The need to have a complete history and physical on the chart prior to the day of the procedure was also identified.

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
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Last Modified: Friday, 12-Mar-10 09:50:25