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: Failure to verify the location of a triple lumen catheter placed in the femoral vessel of an edematous ICU patient by a resident led to the patient receiving 18 hours of pressor and other medications without effect. The catheter placement was verified when the patient’s leg became cold and mottled and ABG’s verified that it was in the artery.

Facility Strategy: The ICU Attending must review the procedure log of each resident working in the unit at the beginning of each shift. Since the opportunity to place these catheters is quite limited, the Attending must also supervise the resident during each procedure. In addition, the ICU Attending staff must develop guidelines to verify the proper placement of the catheter.

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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