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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.

  • Q&A: Joint Commission on workplace violence

    The Joint Commission is the latest healthcare heavy-hitter to call for better protection of healthcare workers, announcing on Tuesday the creation of Sentinel Event Alert 59, which addresses violence—physical and verbal—against healthcare workers. About 75% of workplace assaults occur in the healthcare and social service sector each year, and violence-related injuries are four times more likely to cause healthcare workers to take time off from work than in other kinds of industries.

    Patient Safety Monitor Journal spoke with Victoria Fennel, of Compass Clinical Consulting, about the alert and healthcare’s culture of violence.

    Q: In your opinion, how much of the workplace violence (WPV) issues in healthcare is cultural (behaviors around WPV) vs. policy?
    Fennel: When you think about violence, most of all let me say that it’s a learned behavior. It comes from modeling or observing behaviors in which there was violence. From a cultural perspective, if violence can be a learned behavior, then I think responding to violent behavior must become a learned response.

    You can have all the policies in the world, but if you don’t have some things in place culturally that help leaders and staff understand how to respond to those situations, then it’s not going to be real helpful. It has to be more than just policies and procedures. There has to be some kind of accountability in terms of leadership and how they won’t tolerate certain types of behaviors so that the staff feels comfortable going to authority and expressing things that have occurred where they felt like there was the potential for them to be harmed, be it through verbal abuse or if they experienced physical abuse. 

    Q: How do you keep these alerts from just becoming white noise in the array of things that accreditation and patient safety people have to worry about?
    I think that in and of itself is part of the problem. The concept of workplace violence is more than something that only accreditation and patient safety facilitators need to be worried about. You have to have leadership involved.

    I think if you have the leadership commitment, and I mean true commitment, that certain behaviors will not be tolerated, then I think it helps the organization. Because you’ll have more satisfied staff, and they’ll feel comfortable coming forward with these certain situations.

    At one facility, I heard a chief medical officer say he’d spoken to a physician and said a certain behavior would not be tolerated, and that he could replace the physician faster than the organization could replace a nurse.

    Also, the organization will need to provide the training on how to respond. There’s not enough training that goes on.

    Q: Would better restraint-and-seclusion training, to include de-escalation training, help hospital staffers dealing with abusive patients? And should that include security personnel?
    If an organization is looking at de-escalation in only terms of patients who need to be restrained, then they are not looking at a big enough picture.

    There are many areas within an organization where employees are potentially exposed to violent behavior that has nothing to do with restraining a patient. Many times when we’re looking at de-escalation training in organizations, we’re looking at different areas of the hospital where this is being provided.

    It may be that this training is provided to a limited number of people in the ED or people in the psychiatric department. But what about all the people who have the potential for dealing with this violent behavior all the time (for example, people at the front desk)? And they receive no training, don’t know how to respond, and don’t know what the organization’s stance is in regards to violence. If they are experiencing something, they don’t know if they have the freedom to come forward with what’s going on.

    For example, we know there’s been a lot of violence that’s happened in the surgery area over the years, where it gets to the point that someone is throwing a scalpel at a nurse or a chart that barely misses a nurse’s head. Those are behaviors that cannot be tolerated, but at the same time not a lot of information has been provided to the staff on how to respond in those situations.

    There’s also the fear of retaliation if someone says something, that someone will come back at them because they brought this information forward. There are a lot of things that are involved, but it’s far beyond the scope of just accreditation and safety people to be concerned.

  • Quick look: Immediate Jeopardy

    There’s one facet of accreditation that every patient safety provider ought to know about: Immediate Jeopardy (IJ).

    The CMS State Operations Manual defines Immediate Jeopardy as “a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.”

    It works like this: CMS catches wind of a severe safety violation at your facility and places it under IJ. You are then given a deadline to fix the problem and come up with a plan to ensure it never happens again—and if you don’t, CMS will revoke your facility’s Medicare and Medicaid funding.

    CMS is the largest payer for most facilities, so losing your accreditation can financially cripple your hospital or even force it to shut down. In addition, the loss can negatively impact a hospital’s insurance rates, among other things.

    “[You] lose community support because you are no longer certified or accredited,” says Victoria Fennel, PhD, RN-BC, CPHQ, director of accreditation and clinical compliance at Compass Clinical Consulting. “You start seeing some effects with physicians who may not want to send their patients to that hospital because [it] may affect their payments as well. Then you start to see staff leaving the organization. It really erodes the whole infrastructure if an organization loses its accreditation/certification.”

    This is why, for accreditation and compliance folks, the words “Immediate Jeopardy” carry roughly the same meaning as “why is the tiger cage empty?” It means something has gone very wrong and if you don’t act fast, it’ll get exponentially worse.

    IJ causes
    Richard Curtis, RN, MS, HACP,
    is CEO of the Center for Improvement in Healthcare Quality (CIHQ) and a nationally recognized expert on the CMS Conditions of Participation and certification and survey process.

    “There are literally dozens of situations that can cause an IJ,” Curtis said in an email. “The most common that we’ve seen involve failure to maintain a fire-safe environment (e.g., an inoperable monitoring system), failure to protect a patient from abuse or neglect (e.g., staff physically or verbally abusing a patient), failure to adequately monitor a patient (e.g., a patient in restraint), and failure to assure RN supervision of care.”

    CMS surveyors have a set of principles they follow when determining if a situation calls for an IJ rating. That list includes the following:

    • Only “one individual” needs to be at risk to declare an IJ rating
    • Nobody has to be physically hurt for IJ to be declared; the potential for harm is enough
    • Psychological harm is equally as bad as physical harm
    • An IJ rating will be declared for any case of abuse, even if the abuser doesn’t work at the hospital
    • An IJ rating will be declared for any case of neglect

    The situation that caused the IJ rating could have happened in the past, be happening in the present, or be likely to happen in the future.

    “For example, there was a hospital that was undergoing construction that required closure of multiple exits,” says Curtis. “The hospital failed to change the exit signage, which meant that in the event of a fire, staff and patients would have followed those exits into a dead end. That was an isolated occurrence but a severe breach of safety.”

  • Planning for active shooters in your hospital

    This March, nursing supervisor Nancy Swift was shot to death in her office at UAB Highlands Hospital in Birmingham, Alabama. Swift had been reprimanding a central sterile supply worker, Trevis Coleman, when he pulled out a gun and fired on her. Afterwards, Coleman killed himself, but not before injuring an instrument management supervisor who was on campus.

    When people think of workplace violence in healthcare, they tend to think of loud verbal threats or fighting between patients and providers. However, no discussion on this topic is complete without taking into account gun violence.

    The threat of an active shooter roaming the hallways is one of the biggest fears among safety professionals and C-suite executives in the healthcare industry. Providers have been forced to endure any number of scenarios, such as disgruntled employees, drive-by shootings and gang violence, abusive exes seeking vengeance, and hostage situations.

    Preparedness for active shooter situations is also on the minds of accrediting organizations and agencies such as the NFPA, which in May unveiled a new standard, NFPA 3000, to help first responders, healthcare providers, facility managers, and others prepare for an active shooter incident. CMS, The Joint Commission, and OSHA have also called for better protection of healthcare workers from workplace violence of all kinds, including active shooters, or are currently considering new standards.

    Steve Wilder, BA, CHSP, STS, has spent more than three decades in healthcare safety, security, and risk management, including stints as a hospital risk manager and corporate director of safety and security for a health system. He has consulted with hundreds of clients, including hospitals, clinics, and physician practices, and has trained thousands of workers in workplace safety and security.

    In addition to his regular contributions to healthcare magazines, Wilder co-authored the book The Essentials of Aggression Management in Healthcare: From Talkdown to Takedown.

    During a December 2017 webinar organized by HCPro, Wilder explained how to comply with the revised CMS rule for emergency preparedness and prepare your staff for any situation. He also helped attendees understand the key parts of an active shooter plan, went over how staff can improve decision-making skills, and provided tips on controlling staff anxiety and stress during emergency situations.

    As part of this 90-minute webinar—which can be viewed on demand through HCMarketplace.com—he shared his five key components for an active shooter plan. The following is a summary of that portion of Wilder’s presentation.

    Step 1: Conduct a vulnerability assessment
    Wilder believes the first key component of an active shooter plan is determining threats. Who might pose internal or external threats to your building or campus? How can you assess vulnerabilities that “are the chinks in the armor that allow an opportunity for a bad guy to strike”? Then you should consider the potential outcomes if an active shooter were to barge into your healthcare facility.

    As a consultant, Wilder routinely does vulnerability assessments for healthcare organizations.

    “We come in from the outside and see the things you see every day to the point where you stop seeing them,” he said. “I tell my clients, ‘We’re good guys that get paid to look like bad guys.’ ”

    Wilder said that for an active shooter event to occur, three critical factors must be present.

    “First of all, there has to be a bad guy. The bad guy is always going to be a part of our society. There’s nothing we can do to get rid of him. We can put one in jail and there will be 10 more stepping up to take his place,” said Wilder. “Secondly, the bad guy has to have a motive. I can’t do anything about the motive. That comes from inside his heart or inside his head.”

    He continued: “And thirdly, he has to have an opportunity. … The only thing we can do is take away his opportunity to strike at our place, whether it’s a burglar or an active shooter or an arsonist, a predator, whatever the case may be. The only thing we can do is take away his opportunity, and that’s what the security vulnerability assessment is designed to do.”

    After identifying all the opportunities “for the bad guys to strike,” steps can then be taken to put programs in place “to minimize the vulnerabilities,” which, said Wilder, is “a great step.”

  • Case study: Cutting overridden medication safety alerts at DeKalb Medical

    DeKalb Medical is a nonprofit health system based out of Decatur, Georgia, with 627 beds across its three campuses. The facility was the first in Georgia to receive an international “Baby-Friendly” hospital designation, an impressive feat as America’s maternal mortality rates shoot up. And 83 out of the 800 physicians working for DeKalb were named “Top Doctors” by Atlanta Magazine in 2017.

    But, last October the hospital was placed under immediate jeopardy following the death of a patient with dementia. After being admitted from a nursing home, the patient was given 10 times the maximum daily dose of a calcium channel blocker, causing a fatal overdose.

    DeKalb Medical officers self-reported the incident to CMS and released a statement saying they “want to make sure it never happens again.” The case has spurred a series of patient safety reforms, many of which seek to reduce overreliance on technology.

    "Our staff, physicians, pharmacists, nurses, other healthcare team members—and I don't think this is unique to our hospital system—have become very task-oriented in their actions as it relates to working with an electronic medical record," says Sharon Mawby, MSN, RN, NEA-BC, vice president of patient care services and chief nursing officer for DeKalb.

    "Many hospitals, in an effort to decrease keystrokes for a practitioner, have developed order sets and systems which allow our practitioners to simply check boxes or choose from dropdown screens," she says.

    That efficiency, without proper safeguards, can make it easier for healthcare workers to carry out unsafe orders methodically, without a second thought, Mawby says.

    "Why aren't we asking questions?" she adds. "Why aren't we stopping to listen to our gut when something doesn't feel right?"

    What went wrong
    The doctor who ordered 100 mg of amlodipine besylate tablets failed to second-guess an existing error made by another physician in the patient's file. A pharmacist tasked with reviewing the order missed the error as well, even though DeKalb's medication management system alerted the pharmacist to the unsafe dosage.

    Pharmacists may mistakenly override a medication safety alert because they are inundated with false alarms, DeKalb's pharmacy director told inspectors after the fatal incident, according to an inspection report CMS released to HealthLeaders Media in response to a public records request.

    The rate of adverse drug events originating during an inpatient stay at U.S. hospitals declined 23.8% from 2010 to 2014, falling most dramatically among patients ages 65 and older, according to a study released in January by the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project.


  • Use checklist to reduce self-harm risks in the ER

    There’s a case where a World War II POW committed suicide by hitting himself in the head with an empty metal canteen after days without water. While that happened in the hold of a Japanese prison boat, not a hospital, it highlights how resourceful a suicidal person can be when it comes to finding ways to self-harm. Earbud cords, compact mirrors, trash bags, bed frames, IV tubing, socks, and much more can be used to attempt suicide in a hospital setting.

    With the renewed focus on ligature and self-harm, facilities need to undergo a complete reassessment of the physical environment where patients with behavioral or mental health problems are cared for.

    That goes especially for emergency departments. Annually, 460,000 emergency department visits occur following cases of self-harm, and those patients are six times more likely to make another suicide attempt in the future. To prevent patients from further harming themselves, staff should start each shift by reviewing emergency department rooms designated for treatment of behavioral health patients to remove any items patients could use in a suicide attempt.

    You may want to use a checklist to ensure no items are overlooked. In rooms that can’t be completely cleared of ligatures or other instruments for self-harm, facilities should have trained one-on-one observers available to keep patients safe.

    “As healthcare organizations and accrediting bodies intensify efforts to make the healthcare environment safer, it is critical to use available data and expert opinion to have clear guidelines on what constitutes serious environmental hazards that must be corrected and what mitigation strategies are acceptable in those situations when all potential hazards cannot be removed,” wrote The Joint Commission in a special report on suicide prevention.

    Boarded patients a concern
    When evaluating physical risks in emergency departments, remember that behavioral health patients awaiting transfer to a psychiatric unit or facility may be in the ER for hours, if not days, says Ernest E. Allen, a former Joint Commission life safety surveyor and current patient safety account executive with The Doctors Company in Columbus, Ohio. The company is a medical malpractice insurer.

    Minimizing self-harm opportunities in the physical environment is not only a patient safety issue, but also vital to the hospital’s bottom line, says Allen, who presented an HCPro webinar last November on evaluating the environment of care for suicide risk.

    That’s because patient suicides can not only result in investigations by CMS and your accrediting organization, but also a visit from your local or state department of health and possible fines. Lawsuits from family members can draw unwanted media attention.

    Incidents of self-harm by patients also create poor morale among staff, notes Allen. He recommends you consider designating a room or rooms in your ER area to specifically house psychiatric patients if necessary.

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