Patient Safety Department

Who We Are

The Patient Safety Department is led by a pharmacist with more than 30 years of heath care experience.  Along with an Administrative Assistant this department works collaboratively throughout the medical center to implement known best practices to ensure safe patient care.

Why Is This Important?

In 1999 the Institute of Medicine’s report “To Err is Human: Building a Safer Health Care System” identified that nearly 100,000 people are harmed due to adverse events during their hospitalization. More than half of these were preventable. In the fall of 2008 the Office of Inspector General (OIG) reported to Congress that they found that 15% of patients experienced an adverse event based upon hospital acquired conditions. Clearly patients and their family must become knowledgeable about safe care and what they can do to help prevent these adverse events. Hackensack UMC was the first hospital in the state of New Jersey to appoint a Patient Safety Officer dedicated to such patient care improvements

Our Services

The Patient Safety Department is responsible for implementing many “best practices” which are known to reduce the likelihood of patients being harmed while under the hospital’s care.  The medical center is known for its quality and patient safety efforts including:  US News and World Report- Top 50 Hospitals, Health Grades and being named to The Leapfrog Group Top 50 Safety Hospitals in the nation

This department works with the Quality and Patient Safety Committee of the Board. This committee is comprised of selected members of the Board of Governors, Physicians and Senior Leaders who have been dedicated to leading efforts in reducing hospital acquired conditions.  This year the Quality and Safety Board prioritized and saw dramatic reductions in infection rates while patients were in the hospital, patient falls and decubiti ulcers (bed sore).

The department provides a leadership role in the following areas to make healthcare more reliable, in re-designing systems and processes, identify and mitigate risks in support of safe patient care:

  1. National Healthcare Improvement Efforts/Collaborative Work:
    • Institute for Healthcare Improvement- Medication Safety; Cost and Quality
    • Robert Wood Johnson- Pursuing Perfection Initiative – one of only 7 hospitals selected; work involved the establishment of an Anticoagulation Service and improvements in Medication Safety.
    • Joint Commission – National Patient Safety Goals; Sentinel Event Alerts
    • Institute for Safe Medication Practices- learning from National Newsletters and participating in National Surveys
    • Agency for Healthcare Improvement – Medication Reconciliation
    • National Quality Forum
    • National Quality Foundation – “Safe Practices for Better Healthcare- 34 safe practices”
    • The Leapfrog Group- on a voluntary basis hospitals provide data in measuring established safety practices related to use of Computerized physician order entry, high risk procedures, staffing of specialized physician in Intensive Care Units and other measures that consumers can use to evaluated care of their local hospitals.
  2. Implementation of Safety Technology
    • Computerized Prescriber Order Entry (CPOE) - our electronic health record requires physicians to implement medications directly into a system which provides decision support tools that in combination with pharmacist review significantly reduce the likelihood of inappropriate medication being prescribed for the patient.
    • Smart Pumps- these pumps contain software which alerts nurses and other healthcare providers setting up intravenous drugs (IV) when a maximum drug dose is reached. This prevents programming errors associated with drug administration
    • Bar Coding- the hospital has begun the process of implementing bar code technology to ensure that the correct medication, blood product or breast milk reaches the appropriate patient.
    • Pharmacy Carousel Technology- to be implemented in the first quarter 2012 that would prevent pharmacy dispensing errors through the use of bar code technology.
  3. Implementation of the Joint Commission National Patient Safety Goals- these goals include the following aspects of safe care:
    • Use at least 2 patient identifiers when providing care, treatment and services
    • Report critical results of tests and diagnostic procedures on a timely basis.
    • Label all medications, medication containers and other solutions on and off the sterile field in peri-operative and other procedural settings
    • Reduce the likelihood of patient harm associated with the use of anticoagulant therapy
    • Maintain and communicate accurate patient medication information.
    • Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines
    • Implement evidence-based practices to prevent health care associated infections
    • Identify patients at risk for suicide
    • Conduct a pre-procedure verification process

How services are provided to the patient

  1. Pre- Hospitalization – patients should bring a clear list of all medications being taken including over the counter (OTC) medicines, vitamins and herbal products.  It is important that you keep a copy of this information available with you whenever possible and also recommend that you attach a copy to your refrigerator door or medicine cabinet as first responders (paramedics) who come to your house in the event of an emergency are trained to look there. A medication form can be downloaded here.
  2. During Your Hospital Stay- A couple of important suggestions follows:
    1. Question every test, medication and procedure that is being provided to you. You have a right to know and your participation also serves as a safety net to prevent an error. Remember don’t be afraid to ask questions, it’s your body!!!
    2. Have a patient advocate- this would be a family member or friend who may understand your medical condition or why you are hospitalized and can question any care being provided to you.
    3. The hospital has a safety video which we highly recommend that you view with your patient advocate/family member as soon as possible after being admitted.
  3. Post –Hospitalization- your medication list will more than likely change. It’s important that your After Visit Summary (as our hospital calls it) contains medications that have been updated and accurate.  You should also know what these medications are being used for, appropriate dose and frequency along with common side effects with these medications.  It’s also important that you discuss these medication changes with your primary care doctor as he/she may not have been the doctor responsible for your care while you were hospitalized.

If you have any concerns about patient care and safety at HackensackUMC that have not been addressed, you are encouraged to contact the medical center's management. If the concerns cannot be resolved through management, you are encouraged to contact Joint Commission.


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