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Patient Safety Monitor Journal

Patient Safety Monitor Journal answers your most important patient safety questions and offers field-tested compliance strategies to ensure your patient safety efforts measure up to The Joint Commission.

  • De-escalation: Mitigating violence in healthcare

    The International Association for Healthcare Security & Safety Foundation (IAHSS) in August 2017 released a report to address strategies to prevent workplace violence in healthcare. Those familiar with the healthcare industry won’t be surprised by its conclusion: Healthcare facilities need to take steps now to mitigate violent incidents.

    “Violence in the workplace continues to be a major problem in medical facilities, despite a decline in overall assault rates nationally in recent years,” the report’s authors wrote. “Why are people in these environments so vulnerable? And what can hospitals, emergency care units and mental health facilities do to better protect staff, patients and visitors?”

    The IAHSS touts itself as the only organization solely dedicated to professionals involved in managing and directing healthcare security and safety programs. Its membership includes more than 2,000 healthcare security, law enforcement, safety, and emergency management leaders. The report, titled Mitigating the Risk of Workplace Violence in Health Care Settings, breaks down stressors and risk factors that can trigger disruptive and sometimes violent behavior.

    Ironically, despite the latest warning, IAHSS released a study in 2016 that found violent crime in hospitals had dropped by 68% between 2012 and 2015. Still, the report found that assaults in general were on the rise in U.S. hospitals.

    Available data suggest that healthcare and social assistance workers are far more likely to be injured in an incident of workplace violence than their counterparts in other sectors. In 2014, there were 8.2 injuries related to workplace violence per 10,000 full-time healthcare and social assistance workers—that’s more than quadruple the rate experienced by the private sector overall (which saw 1.7 injuries per 10,000 workers), according to an OSHA analysis of data from the U.S. Bureau of Labor Statistics. Violence rates were highest in psychiatric and substance abuse hospitals, where OSHA found 109.5 intentional injuries per 10,000 full-time workers.

    Officials have long been aware of a need to proactively identify and mitigate threats, which is why OSHA published the first version of its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers more than two decades ago. (The latest version, which was updated in 2015, is available online for free.) These voluntary guidelines, known in the industry collectively as OSHA 3148, include recommended policies and procedures to combat workplace violence in a variety of settings.

    While OSHA (and The Joint Commission and CMS) don’t collectively have standards that lay out specific steps for preventing violence, the consensus seems to be that the healthcare industry will eventually be regulated by standards that will protect workers and patients.

    Since December 2016, OSHA has been “considering whether a standard is needed to protect healthcare and social assistance employees from workplace violence” and has requested public comments on the subject. The public comment period closed on April 6, 2017.

    Federal OSHA is likely to follow in the footsteps of at least nine other states with laws that require employers in the healthcare sector to implement workplace violence prevention policies. In 2014, California passed a law requiring healthcare facilities to, among other things, “adopt a workplace violence prevention plan as a part of its injury and illness prevention plan to protect health care workers and other facility personnel from aggressive and violent behavior.”

    The workplace violence policy must be in place by April 1, 2018, but some of the law’s mandates became effective on April 1, 2017, including a requirement that California healthcare facilities keep a record of all violent incidents.

  • Q&A: The patient safety implications of overlapping surgeries

    A study published in The Journal of the American Medical Association made headlines this November, announcing that overlapping surgeries didn’t increase the risk of postop complications. This study, and several others like it that came out in 2017, suggests the practice may not be as risky as some have feared.

    The study reviewed the cases of 2,275 patients who underwent neurosurgical procedures at the same hospital: 43% had the surgeon stay with the patient for the entire procedure, while 57% had the primary surgeon perform two procedures in different operating rooms.

    In the 90 days following their operations, there wasn’t any difference in morbidity, mortality, or worsened outcome measures between the two groups. That said, the study did find the overlapping surgeries were notably longer than the consecutive surgeries.

    The practice of overlapping surgeries came into the public eye in 2016 after the Boston Globe came out with a lengthy exposé into the practice. There’s been heated debate on the subject ever since.

    PSMJ spoke with Bradley T. Truax, MD, principal consultant of the Truax Group, about the safety and best practices around overlapping surgeries. Truax is board-certified in both neurology and internal medicine and has been involved in patient safety for more than 25 years.

    Q: What’s an “overlapping” surgery?
    First, note the difference between “concurrent” surgery and “overlapping” surgery. No one condones “concurrent” surgery (where critical parts may overlap).

    Overlapping surgery is where a surgeon is present for the entire “critical portion” of the surgery and then moves to another case and lets a resident, fellow, or surgical assistant finish the first case.

    Q: What are your thoughts on overlapping surgeries? And do the findings in this study match your experience?
    There are now at least eight studies that show no excess morbidity or mortality from overlapping surgery (OS) versus one study (the Canadian study) that showed increased complications with overlapping surgery. But the studies are problematic.

    First is the problem with “big data.” Adverse events related to overlapping surgery are not common. Quite frankly, most cases in which overlapping surgery is done proceed without incident.

    As a result, studies which look at large volumes of cases comparing overlapping with non-overlapping cases will never be able to detect which adverse events are the result of overlapping surgery. The latter cases will simply be “diluted out” in the big series.

    The only way you could find that is if you take all the cases with complications and do a root cause analysis on each of them, and then decide if OS contributed to it or was a root cause. Obviously, that’s very time and resource intensive, and there’s very few people who are going to do all that. Theoretically you might do it on a small population, maybe all your hip replacements and just look at all the people who got an SSI. Then do a root cause analysis to tie down whether that infection was due to a prolonged procedure and was the prolonged procedure because it was an OS as opposed to a non-OS.

    Another problem is that even when adjustments are made (such as use of propensity score weighting in the Howard study) it’s almost impossible to get away from selection bias. There’s something that makes these surgeons decide, “Oh, I’m going to do this case as a non-overlapping case.” And sometimes it’s pretty obvious: maybe the patient has a whole bunch of medical comorbidities and they didn’t want to do an overlapping in that case. But you can’t always tell that, and certainly not from the administrative data. And even if you’re doing chart review you can’t tell why the surgeon decided do it as an overlapping surgery or not. 

  • Preventing fires in the OR

    An unplanned fire is the ultimate sign that things have gone sideways.

    Despite being labeled a never event and countless regulations on how to prevent them, fires still break out in hospitals. Between 2012 and 2014 there were 5,700 medical facility fires reported to fire departments. And the ECRI Institute estimates there’s an annual 500–600 fires that occur in, on, or around a patient undergoing a medical or surgical procedure.

    While fires are a rare occurrence in hospitals, when they do happen they can cause an inordinate amount of harm. Now, newly issued advisories about fire hazards in healthcare facilities by safety advocacy groups are placing new emphasis onto the importance of preventing fires.

    Hand sanitizer
    The fire danger of hand sanitizer catches many people off guard. The high alcohol content in hand sanitizer makes it a great disinfectant, but also a major fire hazard, which is why there are strict fire codes that require a collection cup under dispensers and prevent their installation above electrical outlets.

    Fires from hand sanitizer are rare, but they do happen. To illustrate the danger, one only needs to look at the case of James Ditucci, an 8-year-old boy from Boston who was taken to a hospital with major burns after he decided to copy a hand sanitizer stunt he saw on YouTube.

    According to a Forbes report, the boy’s mother awoke to screams and second-degree burns on 15% of the boy’s body after a sleepover with his cousin and 10-year-old brother. Sanitizer got on Ditucci’s hands and shirt, exacerbating the extent of the burns.

    The children were apparently trying to mimic a flaming hand sanitizer video that claims there is a safe method to avoid burning your hands, suggesting it may be done safely if you only handle the flaming gel for a few tenths of a second. The high ethyl alcohol content in the product—up to 62% in some cases—makes hand sanitizer highly flammable and apt to lead to burns.

    A fire in February 2013 at Doernbecher Children's Hospital in Portland, Oregon, left a 12-year-old girl with third-degree burns over a fifth of her body. The girl, who was in the hospital for kidney cancer treatment, reportedly used hand sanitizer to clean a table and olive oil to remove glue residue from leads stuck to her head. She rubbed the plastic mattress she was lying on, and the vapors from the sanitizer caught fire and were fed by the oil in her hair and on her shirt.

    Battery hazards
    The FDA last year issued a warning to healthcare professionals and administrators of the potential safety risks associated with battery-powered mobile medical carts following reports of explosions, fires, smoking, or overheating of equipment. Such incidents have required hospital evacuations, according to the FDA. This warning comes as carts are becoming more widely adopted in clinics, together with the more common use of laptops and other battery-powered equipment.

    “When a lithium ion battery fails, it has the potential of exploding. We had a laptop explode. Fortunately, it was not being carried when it happened,” says Bruce Cunha, RN, MS, COHNS, a former manager of employee health safety at the Marshfield (Wisconsin) Clinic. “Make employees aware that if a battery device starts smoking, [they should] get away from it immediately.”

    Battery-powered medical carts include crash carts, medication dispensing carts, and carts that power medical devices, barcode scanners, and patient monitors, according to the FDA report. They usually have high-capacity lithium or lead acid batteries that are capable of powering devices and computers for hours. In some cases, firefighters have had to bury medical carts to put out the flames.

  • NotPetya and ransomware: Six steps to help you beat hackers

    In the last week of June 2017, foreign-born computer malware attacked the systems of several U.S. companies—including Princeton Community Hospital in Princeton, West Virginia, and Heritage Valley Health System in Beaver, Pennsylvania.

  • Phishing with staff: Using fear to teach cybersecurity

    Phishing emails aren’t just aimed at getting credit card numbers, usernames, passwords, and (in the case of hospitals) patient records and data. They are also used to spread ransomware, like the WannaCry virus in 2017. Consider testing how well staff practice safe email infection control by having your IT staff send a fake message to track who opens an attachment or clicks on a link they shouldn’t.

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