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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.

  • Discharge disaster: Shoeless patient abandoned out in the cold and dark

    A woman was found wandering outside a Baltimore hospital wearing only a hospital gown and socks. The person who found her recorded the scene in a shocking video, which has gone viral. This video can be a training tool to review expectations for dealing with difficult cases at your facility’s emergency department.

    After a video of the woman standing at a bus stop, dazed and barely able to walk, went viral on social media—one news report said it was viewed more than 2.3 million times on Facebook—University of Maryland Medical Center Midtown Campus’ CEO Mohan Suntha promised a full investigation into what he termed “a failure of basic compassion and empathy.”

    The video was taken by a man who said he witnessed hospital security guards bring the woman in a wheelchair to the bus stop. The man confronted the guards, who said the woman had been medically discharged.

    Other than the statement from Suntha saying that the hospital was still “trying to understand the points of failure that led to what we witnessed on that video,” the hospital released no details of what brought the woman to the hospital, what her condition was, or any treatment she received, citing patient confidentiality.

    The man who recorded the video called the police, who had an ambulance take the woman back to the hospital. From there she was sent to a homeless shelter and finally picked up by family members. The Washington Post later talked to the woman’s mother, who said the patient had a history of mental illness.

    While there are a lot of what-ifs about the incident, “we technically don’t know what happened during the encounter,” notes Frank Ruelas, MBA, a patient safety professional and HIPAA consultant who founded HIPAA College in Arizona. “However, there is enough information for us to consider asking questions on how we may have managed this patient if she had presented at our respective ED within our respective hospitals.”

    Regulatory considerations with such a patient would fall under the Emergency Medical Treatment and Active Labor Act (EMTALA) as well as discharge planning expectations, says Ruelas.

     

  • Scanning for maternal disease

    On July 1, 2018, The Joint Commission will implement three new elements of performance (EP) for maternity care. The announcement, which came in the latest R3 Report, is intended to reduce the risk of transmitting diseases like HIV and syphilis from mother to newborn.

    “The requirements will help improve maternal and neonatal health in Joint Commission–accredited hospitals and critical access hospitals across the country,” said Kathy Clark, MSN, RN, Joint Commission associate project director specialist in the accreditor’s Division of Health Care Quality Evaluation, in a press release. “If left undiagnosed or untreated, infectious diseases can be extremely dangerous and even life-threatening, so it is critical that testing and treatment for both the woman and baby is completed according to clinical practice guidelines.”

    The EPs say that when a pregnant woman arrives at a hospital to give birth, the hospital must check her medical record to see if she’s been tested (during her current pregnancy) for:
    ·    HIV
    ·    Hepatitis B
    ·    Group B streptococcus (GBS)
    ·    Syphilis

    If she hasn’t, then the hospital needs to run all four tests and document the results. Since GBS testing can take 24–48 hours, providers can choose not to do it, but only if they give the patient prophylactic antibiotics instead. And if the mother tests positive for any of the diseases, then that information needs to be documented in the newborn’s records as well.

    David B. Nelson, MD, FACOG, medical director of prenatal clinics for Parkland Health & Hospital System in Dallas, says the reason tests are mandated for these particular pathogens is because they carry a heavy risk of vertical transmission: passing a disease from mother to infant. For example, without treatment, the risk of vertical transmission of HIV can be as high as 25%.

    “To emphasize the importance of testing for these infections, in the state of Texas there were 374 cases of congenital syphilis from 2011 through 2015,” Nelson says. “This is an effort to reduce those rates of infection.”

    It’s not safe to assume that people will know if they have these diseases, he says. Syphilis, for example, can go unnoticed if the primary lesion is missed or the patient is asymptomatic. As for HIV, up to one out of seven Americans who have it may not know they are infected.

    “Patients who don’t have the diagnosis of HIV but are infected are not receiving treatment that could improve some of the conditions they may know or unknowingly have,” he says. “This effort is not just to address the current pregnancy during prenatal care, but to also act as a window into the future health needs of these patients.”

    Most hospitals already test pregnant women for the diseases on the R3 report, he says, including Parkland. The Joint Commission’s goal then is to reinforce the practice. But the new EPs also serve to address a major problem: a lack of access to maternity care. For example, in Texas, 26% of women didn’t have a personal doctor in 2016.

    “[The R3] also addresses the fact that some women don’t receive adequate prenatal care according to clinical practice guidelines,” he says. “So this effort is to promote timely testing for both the mother and the newborn, if the screening hasn’t been done in that patient.”
     

  • 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.
     

  • 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.
     

  • Update: CMS memo defines ligature risk and clarifies expectations

    A new CMS memo creates a definition of a ligature risk, a time frame for correcting them, and interim guidance for surveyors, plus requirements for requesting a time extension for a plan of correction taking longer than 60 days.

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