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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.

  • 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.

  • Raise the bar on pain management and opioids

    With the end of the opioid/painkiller crisis nowhere in sight, it’s up to providers and facilities to lead the charge.

    More than three dozen bills addressing various concerns about the opioid epidemic are before committees in the Senate and House. The Centers for Disease Control and Prevention (CDC) issued restrictive new guidelines for chronic-pain prescribing in March 2016, and the President’s Commission on Combating Drug Addiction and the Opioid Crisis was established a year later.

    States, however, have been ahead of the feds, with many instituting tough prescribing and dispensing restrictions; for example, effective January 1, 2018, North Carolina’s STOP Act restricts acute-pain opioid prescription amounts to five days and postoperative opioid prescriptions to seven days.

    In some cases, payers have reacted with their own restrictions. “Some insurance carriers are beginning to decline coverage for any opioids prescribed beyond the protocol recommended by the CDC,” says Nancy Irwin, PsyD, primary therapist at Seasons Recovery Centers in Malibu, California.

    And hospitals can make their own policies, too. Institute a policy on opioid prescribing to relieve your providers of some decision-making pressure in an age of addiction awareness—and, if you do it right, your providers should still be able to give patients the pain relief they need.

    Do more than bare minimum
    It is, of course, important to keep up with the law, which can vary significantly from state to state. For example, in New York, all prescriptions, including those for controlled substances, must be electronically written except in emergencies, while in other states a paper prescription is required.

    “We have to write out the scrips—can’t call it in at all,” says Barbara Bergin, MD, an orthopedic surgeon with Texas Orthopedics, Sports and Rehabilitation Associates in Austin, Texas. “We can call in Tylenol #3—which people who are habituated don’t like because it’s not strong enough for them. But anything stronger has to be written out on a prescription, which the patient has to hand deliver to the pharmacy.”

    And in some states like New York, it’s the provider’s responsibility to keep tabs on their patients’ opioid prescription history via prescription drug monitoring programs (PDMP), says Kate Fuss, a surgical physician assistant most recently with hospitals in the Greenwich, Connecticut area.

    In addition, revised pain management standards by The Joint Commission, effective January 1, include a new Leadership standard, LD.04.03.13, featuring an element of performance that requires hospital leadership to provide clinicians and pharmacists access to their state's PDMP.

    Beyond whatever your state or local authority having jurisdiction requires, your policy on opioids is, to a great extent, your hospital's call, and experts suggest that you nail that policy down to protect both provider and patient.

    Some prescribers have worked out their own ways of dealing with a patient whose PDMP record shows a recent opioid prescription. “Typically, I will prescribe them a third to a half of the original prescription I was going to write for [patients], as they do need appropriate pain coverage post-operatively,” says Fuss. “Typically, there is not much pushback.”

    When she gets “pill-counting” behavior—that is, when patients specifically comment on how many pills they have and how many they think they need—“the encounter becomes slightly more complex,” she says. If she’s getting nowhere with the patient, she defers to a pain management specialist, either the patient’s own or one to whom she refers.

  • Case study: Harborview Medical Center's automated sepsis alert system

    Sepsis mortality rates increase quickly when left untreated, even if it’s only for a few hours. The difficulty facing providers is that there isn’t a simple test for sepsis. Instead, they have to watch for patterns and symptoms that could indicate sepsis. As a result, it’s common to have misdiagnoses or delays in diagnosis.

    Sepsis is also the most fatal complication for burn victims, accounting for 50%–60% of burn injury deaths. That last issue is a particular concern for places like Harborview Medical Center in Seattle. The facility is the only designated Level I trauma and burn center in Washington state and is the regional trauma and burn referral center for Alaska, Montana, and Idaho. The 413-bed facility has around 17,000 admissions, 259,000 clinic visits, and 59,000 emergency department visits annually.

    Rosemary Grant, BSN, RN, CPHQ, is the sepsis coordinator at Harborview. She says her facility chose to focus their attention on sepsis detection because the condition is “prevalent, expensive, and deadly.”

    “When we looked at data from our hospital and others, we saw that patients who develop sepsis in the hospital have a much higher mortality than patients who arrive in the emergency department with sepsis,” says Grant. “So, we knew we needed to focus on faster identification of sepsis in our inpatient population.”

    The evidence backs up her concerns. A 2017 study found that while sepsis is only present in 6% of hospitalizations, it accounts for 15% of in-hospital deaths. In 2014 alone, there were 1.7 million sepsis hospitalizations and 270,000 sepsis deaths in the U.S. It’s also one of the most expensive medical conditions, costing tens of billions of dollars annually. And sadly, despite increased awareness of the condition, mortality rates are rising.

    In 2011, the Harborview team decided to fight sepsis by changing the way they detected it. Working in-house, they developed an automated flagging system for their electronic health record (EHR).

    After a patient is admitted to Harborview, his or her vitals are plugged into the EHR several times each day. The system searches for patterns, trends, and symptoms that might indicate sepsis. If found, a red box appears around the patient’s name and the nurse is assigned a task in the EHR to screen the patient for infection.

    The nurse then assesses the patient for non-sepsis causes for the readings. If the nurse thinks the patient could have sepsis, then the physician is alerted. The system is designed so it won’t sound more than once every 12 hours, she says, so nurses won’t get more than one alert per patient per shift.

    “I think the most important component of our system is that it incorporates the bedside nurses’ clinical judgment,” says Grant. “The alert is just a computer algorithm, and if it paged the provider every time, they would become tired of it very quickly. Instead, it asks the nurse who is spending his/her shift with a patient whether infection is suspected based on abnormal vitals and the patient’s overall clinical picture. It’s only if and when the nurse suspects infection that the provider is notified.”

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