Commentary:
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January 2008 - Wrongful Death Veto: VPP and
other members of the Grieving Family Coalition find
Governor Corzine's veto disingenuous to say the least
since his recommendations could have been easily incorporated
in the bill if the Governor's Office had entered into
constructive dialogue with proponents of the Bill early
on in the process. What is encouraging is there is no
mention of caps in his statement. The Governor also
asks the legislature to revisit this matter and we have
been told leadership in both houses is willing to do
so--this time with the Governor's support. So while
we may be dismayed at what transpired after two years
of work to get the bill to the Governor's desk, there
is hope. CCJ, AARP, The Grieving Family Coalition and
the sponsors of the bills will meet early in February
to start planning the process once again.
November 2007 - Preventable Medical Errors (A-4327/S-2916):
The New Jersey Legislature recently passed A-4327, a
bill amending the Patient Safety Act. The bill requires
the public reporting by health care facility of the
number of serious preventable medical errors committed
in each hospital annually. This important consumer legislation
provides citizens essential quality information in choosing
health care facilities and offers the needed incentive
for hospitals to make quality care a priority. The
bill awaits action in the Senate (S-2916).
Please contact your State Senator and the Commissioner
of Health and Senior Services to support this bill.
WHAT IS A PREVENTABLE MEDICAL ERROR?
A Preventable Medical Error (PME) is a serious or fatal
medical mistake. These errors can be prevented, so they
should never happen. They include falls that are linked
with a patient’s death, leaving something in someone’s
body after surgery, giving the wrong prescription drug
to the wrong person and surgery on the wrong person
or part of the body.
HOW MANY PREVENTABLE MEDICAL ERRORS ARE THERE?
According to an Institute of Medicine report in 1999,
PMEs cause up to 98,000 deaths annually. However, results
from a Health Grades study conducted in 2004 found a
much higher number: 195,000. “If the Centers for Disease
Control’s annual list of leading causes of death included
medical errors, it would show up as number six [on the
list], ahead of diabetes, Pneumonia and Alzheimer’s
disease,” said Dr. Samantha Collier Health Grades’ Vice
President of Medical Affairs.
WHO IS AFFECTED?
Any patient is a potential victim of a PME. However,
some are more likely to experience errors than others.
A New Jersey report released by the Department of Health
and Senior Services (DHSS) found most of the Garden
State’s reported events involved older patients and
those with longer hospital stays. A University of Washington
study revealed that Spanish-speaking patients who need
interpretation had TWICE the risk of “serious medical
events” as those who didn’t need interpreters. A 2007
study showed that among 250 preventable medical errors
on patients with limited English proficiency, 52% of
the errors were related to communication problems.
WHAT ARE THE COSTS ASSOCIATED WITH PREVENTABLE
MEDICAL ERRORS?
According to the Health Grades study, these errors cost
more than $6 billion each year in added health care
costs. The New Jersey report revealed that the most
common consequences of PMEs were longer hospital stays,
additional patient monitoring and additional diagnostic
and lab testing. All three mean higher bills to the
consumer, the insurance company and the hospital itself.
In cases where a medical error means the patient needs
further surgery or more intensive care, it is the patient
who bears that additional cost. This cost is most often
carried by the patient since fewer than one in eight
cases of PMEs ever result in a malpractice lawsuit.
WHAT CAN WE DO TO PREVENT PREVENTABLE MEDICAL
ERRORS?
Required reporting of these errors increases the likelihood
that hospitals will take these events seriously and
respond with system changes to reduce errors. According
to a 2006 Rutgers study of New York hospitals, 50% of
interviewed hospital personnel believe that required
reporting increases accountability and therefore increases
the level of awareness and attention to patient safety.
Currently 24 states have at least one formal reporting
system.
WHAT IS THE NEW JERSEY LAW?
The Patient Safety Act was passed in 2004. Under the
current law and proposed regulations:
1. Mandatory reporting of 25 PMEs is required of all
licensed facilities in New Jersey including hospitals,
assisted living programs, long-term care facilities,
home health care agencies, hospice care providers, residential
health care facilities, and ambulatory care facilities.
2. PMEs will be reported within 5 days. Additionally,
a second report called a root cause analysis (RCA) will
be submitted within 45 days of the first report, evaluating
the event and its cause.
3. Facilities that fail to report errors or fail to
inform the patient of such events can be fined.
4. A Safety Committee will be established in each facility
to review events and establish safety plans. 5. Information
obtained through the reporting requirements cannot be
subject to legal review.
HOW EFFECTIVE IS NEW JERSEY’S CURRENT LAW?
In 2005, the DHSS issued a Patient Safety Initiative
Summary Report which highlighted the first year of data.
Hospitals reported 376 events, of which 57 resulted
in death. Most of the events involved older patients
and those with longer hospital stays. Based on the data
submitted, the most common causes fell into two categories:
Communication problems and inconsistency in staff training
& performance.
HOW CAN WE IMPROVE NEW JERSEY’S LAW?
PUBLIC DISCLOSURE Publicly releasing data using hospital-specific
information increases accountability and creates meaningful
change. According to a Quality Counts study, publicizing
medical errors resulted in significant hospital process
changes to improved quality at under-performing hospitals.
A 2007 survey showed 95% of New Jersey AARP members
say it is very important for the State of New Jersey
to work to prevent medical errors in health care facilities.
And 81% feel these reports should be made available
to the public to allow individuals to compare quality
among health care providers. For more information, contact
Patricia Kelmar at AARP New Jersey at (609) 452-3906
or pkelmar@aarp.org.
November 2007 - Wrongful Death Act (A-1511/S-176):
Voices for Patient Protection has sent the following
letter to Assembly Speaker Roberts, Senate President
Codey and Senator John Adler, Chair of the Senate Judiciary
Committee in support of the Wrongful Death Act.
I am writing on behalf of Voices for Patient Protection,
Inc. a New Jersey, non-profit, 501(c)(3) corporation
founded by individuals, and their families, who are
victims of medical malpractice to ask your support
for A-1511/S-176 which amends New Jersey’s
Wrongful Death Act to expand damages available to grieving
families when the life of a loved one is wrongfully
taken.
As Michael Barrett, Esq. so clearly states our concern,
“family relationships such as husband and wife, and
parent and child, are the most fundamental elements
of our society. When an individual loses a spouse, child
or parent as a result of the tortious conduct of another,
the emotional consequences are usually devastating.
The common perception is that our law provides a remedy
in those circumstances. To the contrary…., New Jersey's
Wrongful Death Act prohibits any recovery for the emotional
consequences caused by the loss of a close family relationship,
and instead treats the death of a loved one as strictly
a matter of economics. With the act's focus upon economics,
substantial recoveries are possible with deaths involving
high wage earners. However, with deaths involving children
or seniors, the act often provides relatively minimal
or no remedy at all.”
Thank you for your consideration of this matter.
Thomas E. Ricker
Vice-President Voices for Patient Protection, Inc.
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