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Patient Safety Monitor is the premier online destination for news, analysis, and training in the patient safety community.

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  • Patient Safety Crosswalk: an interactive grid that organizes state, CMS, and Joint Commission requirements by topic
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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.

  • PSS-3: Three-question suicide screener for the ER

    In the chaos of the emergency department (ED), it’s easy to miss something you’re not searching for. Up to one in five people who die by suicide visit an ED in the four weeks prior to their death. And those who die by suicide are more likely to come to the ED with a non-psychiatric complaint than a psychiatric one.

    We’ve run an ER checklist of items to be removed from rooms designated for treatment of suicidal patients. But that doesn’t help patients who aren’t screened for suicidality.

    Enter the Patient Safety Screener 3 (PSS-3), a suicide screening tool developed for the fast-paced world of the ED. The tool consists of a short introduction and three questions, with an optional fourth item if the person has previously attempted suicide. It’s meant to be given during triage or primary nursing assessment and has been validated for use on patients 18 and older.

    The three questions are:
    Over the past two weeks, have you felt down, depressed, or hopeless?
    Over the past two weeks, have you had thoughts of killing yourself?
    Have you ever attempted to kill yourself?

    If the person answers “yes” to item three, then you follow up by asking them when the suicide attempt took place.

    A “yes” to question one is a positive screen for depression. A “yes” to question two or if the person’s attempted suicide in the last six months is a positive screen for suicide risk.

  • The pipes are calling: CMS revises Legionella requirements

    You can expect renewed interest in your water management program. This summer, CMS sent out a new memo updating its expectations on Legionella infections. The memo, QSO 17-30-Hospitals/CAHs/NHs, was published July 6. It supersedes the former S&C 17-30-Hospitals/CAHs/NHs, issued in June 2017, and adds more specific expectations for long-term care (LTC) facilities. The update also helps clarify expectations for hospitals and nursing homes.

    The Legionella bacterium is responsible for legionellosis: a respiratory disease that can cause a type of pneumonia called Legionnaires’ disease, which kills about a quarter of the people who contract it. Legionellosis is especially dangerous for patients who are older than 50, who smoke, or who have chronic lung or immunosuppression conditions.

    The bacterium breeds naturally in warm water and can usually be found in the parts of hospital systems that are continually wet. Poorly maintained water systems have been linked to the 286% increase in legionellosis between 2000 and 2014. The CDC says there were 5,000 reported cases of it in 2014 alone, with about 19% of outbreaks in long-term care facilities and 15% in hospitals.

    While there are no new expectations for hospitals or critical access hospitals in the revised CMS memo, it does add a specific statement that “facilities must have water management plans” as well as a new note that testing for waterborne pathogens is left “to the discretion of the provider,” according to the letter to CMS’ Quality, Safety and Oversight (QSO) group, formerly the Survey & Certification (S&C) group.

    “The terms ‘plans’ and ‘policies’ are sometimes confusing to hospitals,” warns Kurt Patton, the former director of accreditation services for The Joint Commission and founder of Patton Healthcare Consulting, now in Naperville, Illinois.

    “The Joint Commission already requires a utilities management plan, and water is a component of that. The unknown will be if CMS surveyors say they don’t want to look at a utilities plan, they want to look at a water management plan,” explains Patton. “At a minimum, I would suggest accredited hospitals have a table of contents and a subject header for ‘Water Management Plan’ inside their overall utilities plan.”

  • Improve patient mobility in five easy steps

    The benefits of mobility among hospitalized patients are well-known: decreased pressure ulcers, deep vein thrombosis (DVT), and functional decline, to name a few.

    “Hospital-acquired pressure ulcers, falls in the hospital, falls that cause injury, DVTs, and pulmonary emboli are also caused by immobility," says Maggie Hansen, RN, BSN, MHSc, senior vice president and chief nurse executive at Memorial Healthcare System in Hollywood, Florida. "They have other factors that contribute to them, but [nursing] is taking ownership for preventing some of those things that should never happen to patients."

    Still, finding the time to ambulate patients during a busy shift is something nurses often struggle to do.

    "We heard feedback [from nurses] like, 'I really wish I had more time to ambulate my patients,' " says Leslie Pollart, RN, MSN, MBA, director of nursing at Memorial Regional Hospital in Hollywood, Florida. "While they knew it was important, competing priorities often impeded their ability to ensure timely patient mobility, and sometimes patients need more than one person to assist them in getting out of bed."

    To address this issue and ensure patients were getting the ambulation they needed to achieve optimal outcomes, the hospital revamped its mobility program, including creation of a designated mobility team.

  • Q&A: Focus put on dialysis

    In patient safety, when hospital accreditors take an interest in something, you should as well. That is why you should be paying extra attention to your dialysis procedures.  Each year, 468,000 patients receive dialysis as treatment for end-stage renal disease (ESRD), and surveyors have been cracking down on compliance.

    Jennifer Cowel, RN, MHSA, is president of Patton Healthcare Consulting in Naperville, Illinois, and Kathleen Good, MSN, RN, is an associate of the company. They are both Joint Commission alumni and spoke with PSMJ about maintaining a safe dialysis program.


  • Eight steps to prevent and respond to sexual harassment by non-employees

    Most employers are required by Title VII of the Civil Rights Act and state law to guard against and respond to claims that an employee was sexually harassed by a coworker or manager. However, what employers may not know is they can also be liable for sexual harassment of an employee by non-employees, such as sales representatives, patients, or referral sources.

    Non-employee sexual harassment, also called third-party sexual harassment, is common, says attorney Sarah Carlins with Houston Harbaugh in Pittsburgh. The employer can be liable for acts of a non-employee if the employer knew about the conduct and failed to take immediate and appropriate corrective action.

    For example, Southwest Virginia Community Health System paid $30,000 to settle an Equal Employment Opportunity Commission (EEOC) sexual harassment suit brought by a female receptionist at one of its clinics. She had complained to her supervisor that a male patient was sexually harassing her, but no action was taken to stop the abuse. The health system also had to conduct training on sexual harassment prevention, post a notice about the settlement, provide a copy of its sexual harassment policy to all employees, and report new complaints to the EEOC.

    The EEOC also has filed a lawsuit against Home Instead, a California homecare provider that refused to reassign a homecare worker who had reported being sexually harassed by a client.

    Remember that accreditors are watching whether you are protecting your workforce. The Joint Commission earlier this year issued a Sentinel Event Alert to bring awareness to physical and verbal harassment of staff.

    Physician offices, homecare facilities, or other settings in which employees are in close working proximity with patients and others, and in which the setting is often more intimate and personal, may be especially vulnerable to sexual misconduct claims, including third-party ones. Patients and referral sources wield considerable power because they bring in revenue, says attorney Audrey Mross with Munck Wilson Mandala in Dallas. “It’s about power.”

    Of course, it’s harder to take corrective action against the harasser when he or she is a third party because a provider doesn’t have the power to directly discipline and/or fire that person, points out Mross. But the employer still has a legal obligation to provide a safe environment for its employees.

    “This is a developing area. We’ll see more people emboldened and comfortable speaking out. People are reevaluating the behavior they’ve received,” Mross says.

    It also helps if you’re not one of the 12% of healthcare practices that don’t have a sexual harassment policy.

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