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Trenton, NJ 08625-0360

For Release:
October 14, 2009

Heather Howard

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Office of Communications
(609) 984-7160

DHSS Releases First Data on Serious Medical Errors by Hospital


With today’s release of the 2009 Hospital Performance Report, the state for the first time has hospital-specific information on medical errors that consumers can use to make important health care decisions for themselves and their families, Health and Senior Services Commissioner Heather Howard announced today.


            New Jersey is a national leader in promoting health care quality and transparency by giving consumers the facts they need,” Governor Jon S. Corzine said.  “This landmark report will contribute to safer health care for everyone in our state.”   


The interactive, web-based Hospital Performance Report is available at For the first time, the report describes individual hospital performance on 12 nationally-recognized patient safety measures.  In addition, the sixth annual report provides a 2008 update on how well hospitals performed on quality-of-care measures for treatment of heart attack, heart failure, pneumonia and patients undergoing surgery.


“The ultimate goal is to eliminate medical errors,” Commissioner Howard said.  “By publicly reporting hospital’s scores, we encourage all hospitals to improve care.  Over the last six hospital performance reports, quality of care has improved dramatically in the areas we report on.  This year, New Jersey met or exceeded national averages in 24 of 25 measures of quality care.”  


Earlier this year, Governor Corzine signed legislation requiring hospitals to publicly report medical errors using specific “Patient Safety Indicators” developed by the federal Agency for Healthcare Research and Quality.  The law required patient safety updates in each year’s Hospital Performance Report.


“The sixth annual hospital performance report, with its expanded data on health care quality and patient safety, demonstrates the Department’s and QIAC’s continued commitment to improving health care quality in New Jersey,” said Maureen Bueno, PhD, RN, co-chair of the Commissioner’s Quality Improvement Advisory Committee and assistant vice president, care management and medical informatics for QualCare, Inc.


"This report is further evidence that sharing performance data among hospitals leads to more effective quality improvement and patient safety programs,” said Fred Jacobs, M.D., J.D., co-chair of QIAC, and executive vice president and director of the Saint Barnabas Quality Institute of the Saint Barnabas Health Care System. “All hospitals and physicians work hard every day to improve the care provided to patients. This very comprehensive work by the Department of Health and Senior Services is extremely important to help us all further this goal."


 “Commissioner Howard is to be commended for her leadership in making New Jersey one of the first states in the nation to allow the public to see these important patient safety indicators.  Other states should follow New Jersey’s lead and empower consumers with this valuable data,” said Patricia Kelmar, associate state director for advocacy for AARP New Jersey and a member of QIAC.


“AARP advocated strongly for public release of this information.  When our members are looking for a health facility, they want to choose one that is working the hardest to reduce the number of medical errors to zero,” she added.  “This report shows that every hospital can be doing more to protect patients from preventable mistakes that cause injury, pain and even cost them money."


According to the patient safety section of the performance report, hospitals reported 9,381 adverse events for 2007.  Using hospital discharge records, the report gives the number of adverse events for each Patient Safety Indicator, as well as both New Jersey and national average rates for that indicator.  The report notes when a hospital’s score is statistically significantly better or worse than the statewide rate.


Results vary widely among hospitals and even among the patient safety indicators for each hospital. 


Statewide, New Jersey performed better than, or as well as, the nation in 10 of 12 patient safety measures, using the most recent available national data (2004). 


Among the most rare events statewide are those considered “never events” by the federal Centers for Medicare and Medicaid Services.  There was one major reaction to a blood transfusion (for a rate of zero events per 1,000 discharges) and 63 instances of a foreign object accidentally left in a patient during a surgical or other procedure (for a rate of 0.1 events per 1,000 patients having that procedure). 


Potentially preventable trauma cases were less rare, according to the report.  These include maternal injuries during a vaginal birth requiring the use of forceps or other instrument assistance (907 cases or 173.6 per 1,000 instrument-assisted vaginal deliveries).  New Jersey’s rate for this indicator was better than the U.S. rate. 


In the quality-of-care section of the Hospital Performance Report, hospitals are scored on 25 measures of quality health care.  The measures represent nationally recognized best care practices – such as giving aspirin to a heart attack patient upon arrival, or giving heart failure patients written care instructions upon discharge – that give patients the best chance for full recovery.


Hospitals continued to improve in 2008.  Statewide, hospitals exceeded national averages on 15 measures of quality care, tied the nation on nine, and fell below on one.   Many New Jersey scores were at or close to 100 percent. The difference between high- and low-performing hospitals in the state continues to decrease, which means better care for all patients.


This year, two new measures were added to the report -- controlled blood sugar for heart surgery patients and safe hair removal for those undergoing surgery.  High blood pressure after surgery increases infection risk.  Using a razor to remove hair from the surgical area before surgery also increases infection risk, and clippers and hair removal cream are safer.


New Jersey has undertaken several major initiatives over the years to improve patient safety and health care quality.


Governor Corzine signed legislation in 2007 that required hospitals to report to DHSS cases of patients developing infections related to their health care. Hospitals began reporting in January 2009, and that data will be included in next year’s performance report.


In addition, under the state’s Patient Safety Reporting Initiative, hospitals and licensed surgery centers are required to engage in a confidential process of review and analysis under State supervision for every “never event” that takes place.  This mandatory root cause analysis leads to system changes to prevent the problem from recurring.  In the past, the Department has also worked with the industry on programs to reduce patient falls and to improve congestive heart failure treatment.


As part of the Department’s commitment to making high-quality data available to consumers and hospitals, DHSS also publishes consumer reports on cardiac surgery, other measures of inpatient quality care, and prevention quality indicators, which are available on the web at:


The web-based 2009 Hospital Performance Report has been redesigned for easier use.  Viewers can search by hospital name, county or health condition, choose health measures of interest, and create customized comparison charts.  The site also features safety tips for patients and advice on finding quality care. 


The report and detailed data charts comparing 2008 performance to previous years are available on the web at:


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