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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.

  • Harris Health System vs. Hurricane Harvey

    “At one point, we didn’t know if we were going to be able to save the hospital,” says the facilities director.  

    It’s been one year since Hurricane Harvey struck Houston, flooding the city and displacing tens of thousands of people. In one week, the Category 4 storm dropped 61 inches of rain and caused $125 billion in damages. The National Hurricane Center called Harvey “the most significant tropical cyclone rainfall event in U.S. history.”

    Ericka Brown, MD, is chief operating officer at Harris Health System in Houston, which was inundated by floodwaters for more than five days during Harvey. She says to consider prepositioning emergency food and medical items closer to your hospital, and to review the physical location of critical equipment and systems to ensure their continued operation in a natural disaster.

    But, most importantly, she says, “make sure you take care of your staff after the storm.” More than 400 employees from Harris Health had homes significantly damaged or destroyed in the flood. With so many workers impacted by the floodwaters, response and recovery after the storm meant helping staff members as well.

    Harris Health had many sites impacted by the storm, including Ben Taub Hospital, which sits in the heart of a collection of healthcare facilities known as the Texas Medical Center. With 440 beds, Ben Taub is the largest hospital in the Harris Health System, serves as a teaching hospital, and is one of only two Level I trauma centers in the area.

    Houston, barely 50 miles from the Gulf of Mexico, is not unfamiliar with flooding. Each year, storms shut down one or more sections of the interstates that surround and intersect the city, periodically cutting off neighborhood access for hours or even days.

    Over the last few years, the hospital’s Emergency Operations Plan (EOP) has been influenced and updated numerous times after storms, notes Brown, who in the two years prior to Harvey served as Ben Taub’s senior vice president and administrator. Some of those changes came in handy. And “some of those things went out the window, because this was different,” says Brown, noting that until Harvey she had never been through a tropical event.

    And after Harvey? “I have a new appreciation for water,” she says.

    The EOP includes identifying the number of staff members designated to ride out any storm, as well as those who are expected to arrive at the hospital as relief afterward. The staffers are oriented to the plan upon hire and at least once a year, says Brown.

    As Harvey approached, everyone knew their jobs. Emergency systems were checked and supplies were bolstered.

    Those supplies included sand bags. The hospital maintains a supply of sand bags day to day as standard procedure, says Bryan McLeod, a director with Harris Health’s communications department. But extra pallets were brought in ahead of the storm as a precaution.

    And they were going to be needed.

    Slow-moving storm brings epic rain

    Harvey made landfall just east of Rockport, Texas, on the night of August 25, 2017, a Friday. The massive storm system took a full day to move 200 miles north and east until it all but stopped on top of Houston and the surrounding Harris County. In one 24-hour period, more than 26 inches of rain fell, overwhelming the county’s sewer and drainage system. More was to come.

    For Ben Taub, the first problem with water was the rain that was hitting the facility sideways and finding its way inside through new and multiplying leaks. Facility maintenance and engineering staff scurried to plug holes and redirect water into buckets throughout the building, according to information released by Harris Health System after the storm.

    But the real challenge presented itself when water began backing up though the overwhelmed drainage system into the basement of the hospital’s main building. As pressure built on a 6-inch plumbing pipe, it developed a leak that became a crack, then a gash—30 feet long. The rising water also began to threaten food supplies, linens, pharmaceuticals, and kitchen operations.

    As the 16-member maintenance and engineering crew raced to place sandbags at entryways, Ben Taub’s engineering director, Benny Stansbury, put in a call to a very busy Houston city command center for help. He had to leave a message.

    Fortunately, a city official called back within a few minutes, but stressed he could make no promises. An overwhelming number of calls for help were coming in, and conditions outside were still dangerous for any vehicles, floating or wheeled, to navigate. But, the official said, if he could get someone safely out to a pump station to reduce the backflow of water into the hospital, an attempt would be made.

    Within 30 minutes, the backflow was halted.  The maintenance and engineering team worked to deal with the water at hand, using plastic sheeting to funnel water into bins for disposal, lifting supplies and equipment out of harm’s way, and sweeping water out where possible.

  • Q&A: Photos and wristbands for patient identification

    Every time patients are misidentified, they are put at risk. Sometimes the harm is minor: an unnecessary test or being placed in the wrong room. And sometimes the consequences are dire: getting the wrong medicine or having the wrong operation performed. There are numerous points where a mix-up can happen, including at the front desk, during a room change, or during a poorly executed patient handoff.
    Austin F. Mount-Campbell, PhD, is a patient safety fellow at the Center for Medical Product End-user Testing in the VA Pittsburgh Healthcare System. He’s done previous studies on the efficacy of patient ID wristbands and patient handoffs.  

    Q: Why do facilities still struggle with patient ID mix-ups? It seems like it ought to be easy to solve.
    It is a combination of issues, even to the point where different facilities have a different set of issues. Generally speaking, it’s related to facilities’ health information technology—either in their own poor design or in the poor integration into the technology ecosystem.

    Many facilities also have issues with who is responsible for patient ID. Is it the person who checks in the patient? Is it the unit clerk? Is it the patient’s nurse?

    Often, facilities don’t have consistent rules. Sometimes one unit does it one way and you walk down the hall to another unit and things are done differently.

    Beyond that, HIPAA and patient privacy teams aiming to protect patient privacy often create unnecessary rules and restrictions that may hinder what might be commonsense solutions.

    Q: Please tell me about your research on patient ID wristbands. What were the takeaways on the practice and how to improve it?
    My research was related to the accuracy of information on wristbands, why inaccuracies exist, and how we might make them more accurate.

    I found as many as half of patient wristbands had misinformation on them, [but] I don’t want you to mistake misinformation as necessarily being dangerous or a patient safety risk; rarely would I consider that dangerous.

    My major takeaways are on three levels. First, each facility should clearly identify who is responsible for patient wristbands in order to establish consistency and ownership.

    Second, facilities need to remove information from wristbands that changes frequently (e.g., fall risk, which can change multiple times within a single day, meaning the wristband has to change and you’re adding an extra opportunity to introduce errors). This also creates overload or saturation with respect to the wristband. It’s similar to how too many alarms cause issues—less is more.

    Third, we have such wonderful technology that we simply don’t use to our advantage: Wristbands are often generated through computer programs that do not link or communicate with the EHR and function in a silo.


  • Cleanliness sensors: Using technology to improve hand hygiene compliance

    Infection preventionist Jessica Strauch shares an amusing anecdote to show how hand hygiene monitoring technology has improved the culture at Lutheran Medical Center in Colorado.

    Picture one of Lutheran’s nurses standing in front of her kitchen sink at home. Dinner is hot and ready, and the nurse stops to wash her hands before everyone digs in. Then, even though she is out of her scrubs and wearing civilian clothes, she waves her hands in front of an imaginary badge.

    Oh, shoot, she isn’t at work anymore. But hey, at least the nurse remembered to wash her hands without a beep or a buzz from her BioVigil badge reminding her to perform hand hygiene.

    “It’s funny to hear nurses say that,” says Strauch, chuckling.

    Lutheran is among the healthcare organizations nationwide that in recent years decided to try hand hygiene monitoring technology in the hopes it could improve hand hygiene compliance—and in the process reduce the number of infections and avoid citations from accrediting organizations like The Joint Commission, which in January put stricter enforcement in place.

    Previously, a healthcare organization wasn’t punished for individual hand hygiene failures if it had an otherwise compliant hand hygiene program. Now, if a Joint Commission surveyor sees an individual who directly cares for patients fail to perform required hand hygiene, the healthcare organization will receive an RFI under Infection Prevention and Control (IC) standard IC.02.01.01, element of performance 2, which requires organizations to use precautions such as hand hygiene to reduce infection risk.

    “While there are various causes for HAI, The Joint Commission has determined that failure to perform hand hygiene associated with direct care of patients should no longer be one of them,” according to the December 2017 issue of Joint Commission’s Perspectives magazine.

    Additionally, The Joint Commission requires that healthcare organizations meet National Patient Safety Goal (NPSG) 07.01.01, which requires them to implement and maintain a hand hygiene program.

    The majority of U.S. hospitals and outpatient facilities do not currently use hand hygiene monitoring technology, though perhaps the increased surveyor focus on hand hygiene compliance and more success stories like Strauch’s will encourage others to pony up.

    The cost can certainly be a turnoff for cost-conscious C-suite execs. Some employees will be concerned about nonstop surveillance, too. But research shows that, somehow, thousands and thousands of healthcare workers still don’t wash their hands as often as they should despite everything now known about the impact of hand hygiene on infection control. So, it makes sense for organizations that struggle with hand hygiene compliance to at least consider new technology.

    “You hate to see a forcing function,” says Marge MacFarlane, PhD, MT(ASCP), CHSP, CHFM, HEM, MEP, CHEP, principal of Superior Performance in Eau Claire, Wisconsin. “But if you don’t have some kind of forcing function—whether they alarm you or your hands turn blue or your hair turns blue or whatever—I’m not sure if people will wash their hands the way they’re supposed to.”

  • 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 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. 

  • 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.

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