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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.

  • Case study: Five steps from Sentara Health for room cleaning

    Facilities still struggle with infection control, whether it’s hospital floors, fungi on doorknobs, or Legionella in the pipes. And, of course, there’s Clostridium difficile infections, which are among the most frequently reported healthcare-associated infection (HAI) issues. Annually, C. diff infections affect around half a million people and play a role in 29,000 deaths.

    Sentara Healthcare is a health system based out of Norfolk, Virginia that is made up of several hospitals, assisted living centers, hospices, and nursing homes. In 2015, Sentara kicked off a project to:

    • Gauge how well it was cleaning patient rooms
    • Determine best practices for environmental services departments (ESD) to reduce C. diff transmission
    • Ensure each room was disinfected the same way each time

    To meet its goals, Sentara gathered a multidisciplinary team to create a five-step program:

    • Structured interviews
    • Summit
    • Education and training
    • Competency audits
    • Universal checklists

    Using this process, Sentara reduced the number of annual C. diff cases from 368 to 267 between 2015 and 2017. That’s a 27% drop in infections in just two years.

    “The process was new because it was the first time we really pulled everyone together to address room cleaning across our system of 12 hospitals,” says Linda Estep, BS, MT (ASCP), CIC, a Sentara Healthcare system manager of infection prevention and control.


  • Not tolerated: Sexual harassment in healthcare

    Ever since the Harvey Weinstein scandal broke in 2017, there’s been new (and well-deserved) attention placed on sexual harassment, and healthcare organizations are no exception. The industry is rife with examples.

    A surgeon cornered a colleague in a cloakroom after a professional society dinner and insisted he was going to walk her to her hotel room. There was a $168 million lawsuit against a California hospital after a surgeon slapped a nurse’s rear daily while saying “I’m horny.” A Denver nurse was sent to prison for fondling female patients while they were sedated. A nurse was pinned to a bed by a patient and had her clothes ripped off and back clawed.

    Ideally, everyone could go to work without having to worry about harassment. But since this isn’t an ideal world, healthcare organizations (HCO) must get proactive about preventing, investigating, and resolving sexual harassment claims and violations.
    Kate Fenner, PhD, RN, managing director of Compass Clinical Consulting, specializes in organizational optimization, performance improvement, and regulatory compliance. Anyone who has worked in an HCO can recount a harassment story or allegation, she says. And some HCOs are more prone to these problems than others.

    “The very public attention currently being paid makes it even more imperative that executives lead their organizations on this pressing issue,” Fenner says. “Prevention, detection, and remediation are the key components of a successful approach. Thoughtful leaders use all three to assure a safe and productive care environment.”

    And it’s not just the public and newspapers watching. Government agencies and surveyors are also taking notice.

    “Regulators and surveyors (CMS and The Joint Commission) pay careful attention to the news and trends in public interest,” Fenner says. “Allegations of improper conduct, such as that recently lodged against a physician then practicing at a highly regarded medical center, pique regulator interest and focus attention.”

    Types of harassment
    The U.S. Supreme Court has ruled that there are two types of sexual harassment covered by the Civil Rights Act, which recognizes sexual harassment as an infringement on employee’s civil rights:

    Quid pro quo: “Job security, advancement, or benefits are tied to sexual favors. This type includes unwelcome sexual advances, requests for sexual favors, or physical or verbal conduct of a sexual nature that are tied directly or implicitly to employment.”

    This type of harassment is fairly straightforward (“Come to my hotel room and we’ll talk about your promotion.”). It also applies to retribution/punishment for rejecting a person’s advances (“Since you won’t go out with me, I’m demoting you.”).

    Hostile work environment: “Inappropriate behavior is so pervasive and severe that it permeates the workplace and interferes with the individual’s ability to carry out the duties of the job.”

    This type is more subjective and covers a variety of bad behaviors: unwelcome jokes, graphic images, insults, threats, gestures, and touching of a sexual nature. Typically, most quid pro quo cases also include hostile work environments.  

  • 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.”

  • Ransomware and reprocessing lead the ECRI list of top tech hazards

    The ECRI Institute published its annual list of the top 10 health technology hazards for the industry. Readers will note that several of the top hazards in 2018 are the same as those in 2017. To guide readers through the hazards, PSMJ spoke to several experts on the top 10 issues and about steps that can be taken to prevent them.

    1.    Ransomware and other cybersecurity threats
    “Malware is a term that refers to a category of software that can compromise the security and privacy of a computer system,” says Frank Ruelas, MBA, principal of HIPAA College in Casa Grande, Arizona. “Ransomware is unique to other malware in that when it infects a computer or computer system, it encrypts files, which makes them unusable. Ransomware then displays a notice to the user that by paying a ransom, the user will then receive a key that will unencrypt the infected files.”

    With the WannaCry virus and NotPetya virus striking hospitals worldwide last year, it’s not surprising that cybersecurity tops this year’s list. In a healthcare environment, a malware attack can cause canceled procedures and altered workflows (e.g., forcing staff to revert to paper records). They can also damage equipment and systems, expose sensitive data, and force closures of entire care units. Ultimately, they can compromise or delay patient care, leading to patient harm.

    Solutions: “Dealing with ransomware is a classic example of the saying, ‘An ounce of prevention is worth a pound of cure,’ ” Ruelas says. “An organization’s best line of defense regarding ransomware includes efforts to train users on how to identify emails that may present a malware attack.”

    “Often these emails have telltale signs such as poor grammar, typing errors, generic greetings, and are received by unknown senders of an email. Having an effective training and awareness campaign to alert users on how to identify an email that may contain one or more of these telltale signs and on what to do when they encounter one of these emails may be one of the best ways to prevent a ransomware attack.”

    “Should a ransomware attack infect a computer system, information technology (IT) staff should have an established and tested (through drills or other simulations) process on how to shut down the computer system and restore it from available backup copies. The key is to plan what to do in the event of a ransomware attack before it happens rather than trying to scramble and figure out what to do after a system is infected.”

  • 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.


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