Mandatory Reporting Instructions, Forms & Letters

New Jersey Department of Health and Senior Services
Patient Safety Initiative
Office of Health Care Quality Assessment
240 W. State Street
11th Floor
Trenton, NJ 08608-1002
Phone: (609) 633.7759
Fax: (609) 984.7707

These documents were created as part of the Department of Health and Senior Services’ implementation of the “Patient Safety Act,” P.L. 2004, c.9, (N.J.S.A. 26:2H-12.23-12.25) [pdf 19k] Rules (NJAC 8:42 E-10) implementing this act were published at 40 New Jersey Register 1094 (March 3, 2008). Patient Safety reporting began on February 1, 2005, for general hospitals. Psychiatric, Special and Comprehensive Rehabilitation hospitals began reporting on April 1, 2008 and Ambulatory Care Surgery Centers began reporting on October 1, 2008.

Patient Safety Memoranda

• Memo from Commissioner Heather Howard, April 28, 2009 to all licensed assisted living residences, comprehensive personal care homes, assisted living programs, long term care facilities, residential health care facilities attached to another facility type regarding reporting adverse patient safety events effective May 1, 2009. Form available here.
• Memo from Commissioner Heather Howard, February 27, 2009 to all licensed home health care agencies, hospice care providers, and ambulatory care facilities regarding reporting adverse patient safety events effective April 10, 2009.
• Memo from Commissioner Heather Howard [pdf 175k], September 12, 2008 to all ambulatory care surgery centers regarding reporting adverse patient safety events effective October 1, 2008
• Memo from Frances Prestianni [pdf 22k], March 19, 2008, to psychiatric, special and comprehensive rehabilitation hospitals regarding patient safety reporting for health care facilities effective on April 1, 2008
  
  

Patient Safety Instructions for Licensed Health Care Facilities

• Guidance on Development of a Root Cause Analysis for Patient Safety Reporting, March 2008 [pdf 312k]
• Mandatory Patient Safety Reporting Requirements for Licensed Health Care Facilities [pdf 307k], October 27, 2008 (instructions and forms)

Reporting Forms

• Event Reporting Form - HCQ-1 [doc 88k] [pdf 22k]
• RCA Reporting Form - HCQ-2 [doc 61k] [pdf 16k]