Patient Safety, 2005

New Jersey Department of Health and Senior Services

August 2005

An AHRQ-sponsored workshop for State health care leaders and stakeholders, entitled "Making New Jersey a Model for Patient Safety," contributed to the professional dialogue that led to the enactment of the 2004 New Jersey Patient Safety Act. The workshop, which took place in Princeton in August 2003, was conducted as part of AHRQ's User Liaison Program (ULP) for state policymakers.

Some 50 representatives of New Jersey health care associations and advocacy groups learned from Federal and State officials about efforts being made to prevent medical errors. The AHRQ-sponsored workshop generated a far-ranging discussion about ways to achieve a balance between holding facilities and professionals accountable for their conduct and encouraging honest disclosure and analysis of the errors that inevitably occur.

The New Jersey law, enacted April 27, 2004, creates a non-punitive system for the reporting of medical errors, along with new requirements that health facilities conduct internal reviews of adverse events and "near misses." The law applies not only to hospitals, but also to surgical centers, clinics, nursing homes, psychiatric hospitals, home health agencies, and other state-licensed health facilities. The goal of the law is to create a health care culture that focuses on preventing errors by improving its processes rather than assigning blame.

According to Marilyn Dahl, Deputy Commissioner of the New Jersey Department of Health and Senior Services (NJDHSS), AHRQ's two-day workshop "was an important vehicle for raising health care stakeholders' awareness of the importance of medical error reporting." While hospitals have traditionally made use of internal quality reviews of problematic cases, these more formal processes are new to many other types of facilities, she noted.

Protection for peer review is a key ingredient of the new legislation, Dahl adds. Until now, fear of litigation has made health care professionals reluctant to discuss errors. If the desired culture change is to occur, they need to know that their honest sharing of information with one another will be kept confidential.

Disclosing a mistake that has resulted in harm to a patient and family members is an important ethical obligation of a health care professional; however, fear of lawsuits makes it difficult to do. The issue came up for discussion at the workshop, and a solution that was suggested was incorporated into the Patient Safety Act. The law provides that these disclosures are not themselves subject to discovery in legal proceedings, although the patient's medical record continues to remain available should the patient or family decide to sue.

The law directs NJDHSS to emphasize corrective action by the facility or the professional, and to reserve punitive or disciplinary action for cases displaying recklessness, gross negligence, willful misconduct, or a pattern of substandard performance.

Deputy Commissioner Dahl believes her department's educational task has just begun. NJDHSS officials must now create regulations to implement the law, spelling out in detail how internal reviews are to be conducted and adverse events reported.

Impact Case Study Identifier: OCKT 05-04
AHRQ-Sponsored Activity: User Liaison Program (ULP) Workshop
Topic(s): Patient Safety
Scope: New Jersey

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