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What to Report
1. Anesthesia events:
The interim system replaces the old anesthesia reporting system.
Report using the criteria listed in the Interim
Mandatory Patient Safety Reporting Requirements for General Hospitals,
Types of Preventable Events, Surgery-related Events (Chapter II,
Section 5. D) [pdf 323k]
2. Interruption of services, environmental events, communicable
and infectious diseases:
Continue to report those based on the existing procedures:
- Unexpected physical plant and operational interruptions should
be reported within three hours to the Acute Care Survey Unit at
800-792-9770.
- Communicable diseases should be reported in accordance
with the requirements of N.J.A.C. 8:57-1 et seq.
Do not report these events to the Patient Safety Reporting Initiative.
3. Criminal activity:
Notify the Department of alleged criminal events which endanger the life or safety of patients or employees, which are also reportable to the police department, and that result in an immediate onsite investigation by the police. Do not
report to the Patient Safety Reporting Initiative. Instead, contact
the Department’s Acute Care Survey Unit at 1-800-792-9770.
4. Falls:
Report every fall that meets the criteria in Interim
Mandatory Patient Safety Reporting Requirements for General Hospitals, Types
of Preventable Events (Chapter II, Section 5. B4) [pdf 323k]
. This includes, but is not limited to, all falls that result in fractures,
sprains or dislocations that require splinting, casting, pinning or
surgical intervention.
5. Attempted suicides:
Report all attempted suicides.
6. Definition of surgery:
A surgery related-event (Chapter II, Section 5. [pdf 323k]) includes
any invasive manual or operative diagnostic or therapeutic procedures,
including endoscopies, colonoscopies, cardiac catheterizations, and
other invasive procedures.
7. Events that occur in Same-Day-Surgery:
Report all events that meet the criteria in the Types of Serious
Preventable Events, Surgery-related Events (Chapter II, Section 5.
D [pdf 323k]).
8. Retained foreign objects:
If a hospital discovers a retained object as a result of a surgical
procedure that occurred at its facility, then the hospital must report
the event within 5 days and is responsible for performing the RCA.
If a hospital discovers a retained object as a result of a surgical
procedure at another facility, then the discovering hospital must
report the event within 5 days. If the identity of the original hospital
is ascertainable, then the discovering hospital must inform DHSS
where the prior surgery occurred. The discovering hospital is not
responsible for performing an RCA.
9. Uncertain whether an event impact meets the 7 day criteria
for loss of bodily function:
If the 5 day reporting deadline is approaching and you're not
sure if the disability will resolve before 7 days, use your best
judgment and report the event. If the issue resolves within 7 days,
submit a revised report.
10. Near misses or less serious preventable adverse events:
Facilities should not report near misses and less serious events. Once the Department
establishes the voluntary, anonymous reporting system required by
the law, reports of less serious events and near misses will be accepted
from any source.
How to Report Events
1. Time frame:
All events are reportable within 5 business days of the discovery
of the event, or from when the event should have been discovered
by the hospital.
2. Reporting forms:
Event and RCA forms are found in Interim
Mandatory Patient Safety Reporting Requirements for General Hospitals[pdf 323k]
. Forms may also be downloaded from the Patient Safety Website: www.nj.gov/health/ps/report.shtml and
the event information entered and printed.
3. “When the event was discovered?” (Section
2 of report form)
We are asking for when the hospital staff became aware of the
event and responded to it, not when risk management was notified.
4. “How was the event discovered?” (Section
3 of report form)
We are asking for who, or how, the hospital was alerted to the
event's occurrence, not how the event was reported to the risk manager.
5. Patient Information (Section 4 of report form):
Complete both race and ethnicity items based on separate
determinations using the following categories:
Race |
Ethnicity |
Caucasian: A person having
origins in any of the original peoples of Europe, the Middle
East, or North Africa. |
Hispanic or Latino: A person
of Cuban, Mexican, Puerto Rican, South or Central America, or
other Spanish culture or origin. |
Black or African American: A
person having origins in any of the black racial groups of Africa. |
Non-Hispanic or Latino/Unable to determine. |
Asian: A person having origins
in any of the original peoples of the Far East, Southeast Asia;
or the Indian subcontinent. |
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American Indian or Alaska Native: A
person having origins in any of the original peoples of North
and South America (including Central America) and who maintains
tribal affiliation or community attachment. |
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Native Hawaiian or Other Pacific Islander: A
person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islanders. |
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Patient Safety Initiative
