N.J. Admin. Code § 8:43A-12.7

Current through Register Vol. 56, No. 11, June 3, 2024

Section 8:43A-12.7 - Anesthesia continuous quality improvement

(a) The facility's quality improvement program shall include a systematic review and evaluation of patient care, anesthesia practices and anesthesia techniques. The surgical staff shall identify problem-prone processes which manifest undesirable patterns. The facility shall develop a plan by which to collect and analyze data in order to evaluate outcomes or performance of the problem-prone processes. Data analysis shall focus on recommendations for implementing corrective actions and improving performance.

(b) Continuous quality improvement shall include morbidity and mortality conferences.

(c) The facility shall notify the Inspections, Compliance and Complaints Program of the Department, by telephone at (800) 792-9770 or by fax at (609) 943- 4977 within 24 hours, and in writing within 30 days, of all deaths in anesthetizing locations and unexpected events or outcomes related to anesthesia, except those in which the patient expired prior to the administration of anesthesia.

1. The written report shall be submitted on the form entitled "Confidential Report of Anesthesia-Related Incident" (HFE-5), available from the Department and shall include;

i. A summary of the incident and the patient's risk status or the American Society of Anesthesiology (ASA) Physical Status Classification; and

ii. All unexpected intraoperative or postoperative events or outcomes related to anesthesia.

N.J. Admin. Code § 8:43A-12.7

New Rule, R.2003 d.56, effective 2/3/2003.
See: 34 N.J.R. 224(a), 35 N.J.R. 857(a).
Former N.J.A.C. 8:43A-12.7, Anesthesia supplies and equipment; safety systems, recodified to N.J.A.C. 8:43A-12.10.
Amended by R.2021 d.039, effective 5/3/2021.
See: 51 N.J.R. 1316(a), 53 N.J.R. 703(a).
In the introductory paragraph of (c) and (c)1, substituted "Division of Health Facility Survey and Field Operations" for "New Jersey Department of Health and Senior Services"; and in (c), deleted "Inspections, Compliance and Complaints Program" preceding ", by".
Notice of readoption with technical change, effective 1/3/2022.
See: 54 N.J.R. 60(a).