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New Sentinel Event Alert focuses on patient falls prevention

Sentinel Event Alert (SEA) #55, issued by The Joint Commission today, urges healthcare facilities to take action to prevent falls and fall-related injuries.

Falls are routinely in the top 10 sentinel events reported to The Joint Commission each year. The most common causes of falls or fall-related injuries, include poor patient assessment, lack of communication, failure to follow healthcare facility protocols and safety practices, and the absence of strong leadership, according to the SEA.

The Joint Commission recommends the following actions under the command of a strong leadership:

  • Raise awareness of the need to prevent falls
  • Create an interdisciplinary falls injury prevention team
  • Implement a standardized tool to assess possible fall risks
  • Develop patient-specific plans of care based on possible fall and injury risks
  • Create standardized practices and interventions for healthcare professionals and patients
  • Perform a root cause analysis after a fall

Read the SEA for further information on The Joint Commission’s recommendations to prevent falls and fall-related injuries.

Joint Commission launches leadership module on Physical Environment portal

The Joint Commission posted the leadership portion of the management of utility systems (EC.02.05.01) on its Physical Environment portal earlier this week. The first part of the module discussed the impact noncompliance of utility systems has on patient care safety.

The next modules to be released on the portal, in October and November, will cover maintenance of egress integrity (LS.02.01.20) and management of hazardous materials and waste risks (EC.02.02.01).

The Joint Commission and American Society for Healthcare Engineering (ASHE) launched the portal in July to provide hospitals with online resources and tools to comply with the most challenging Life Safety (LS) and Environment of Care (EC) standards.

Visit the Physical Environment Portal.

Joint Commission seeks comments on proposed changes to National Patient Safety Goal on Catheter-Associated Urinary Tract Infections

The Joint Commission is calling for comments on proposed changes to existing NPSG.07.06.01 on Catheter-Associated Urinary Tract Infections (CAUTI). The proposed changes including educating, patients and their families on the importance of preventing CAUTI. Additional proposed changes include requiring consistent documentation methods for indwelling catheter use.

The Joint Commission is also seeking comments on this NPSG for nursing care centers. This is a new NPSG for those facilities.

The comment period for both ends on October 14.

Read more about the proposed changes here.

I saw Mommy kissing the senior engineer…

Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, wrote about recent mid-term release of The Joint Commission’s Survey Activity Guide.

Late last week, The Joint Commission provided information regarding the mid-term edition of this year’s Survey Activity Guide (SAG—and no, I will not make any gratuitous remarks about that particular acronymic confluence…), which includes “new description for Facility Orientation-Life Safety Surveyor and minor revisions to Environment of Care Session and Life Safety Building Tour for hospitals and critical access hospitals.”

While the minor revisions to the Environment of Care session and Life Safety building tour are indeed just that (with one exception that you already know about—more in a moment), it appears that Santa Mills has left us a nice little package under the Christmas in July tree: a new Life Safety and Environment of Care Document List and Review Tool (just think, kids—now you can survey like a real surveyor!). While I jest a wee bit (jester that I am), I do think that this is a pretty useful thing for the good folks in Chicago to be sharing. I think you’ll find the tool may give you a sense of “what” they’re looking for in terms of documentation; it also contains a nifty little typographical error. Let’s see who has the eagle eyes out there in radioland…

The one change that is a little more than minor (if only for its far-reaching consequences in surveys the past 18 months) is the instruction for surveyors to assess operating rooms for proper pressure relationships.

Continue reading this post at Mac’s Safety Space.

The Joint Commission updates FAQ section

In case you missed it, The Joint Commission added a new frequently asked question (FAQ) and updated 19 existing FAQs last week. The new question tackles the issue of physician texting medical records.

You can read the updates here.

Joint Commission releases Easy-to-Read 2012 NPSGs

Earlier this week The Joint Commission released the National Patient Safety Goals (NPSGs) for 2012 in an easy-to-read version. Goals for 2012 include identifying patients correctly, improving staff communication, using medications safely, preventing infections, identifying patient safety risks, and preventing mistakes in surgery.

Click on the program links below to view/download the 2012 NPSGs.

For more information, visit The Joint Commission Website.

Latest Sentinel Event Alert:Radiation risks of diagnostic imaging

The Joint Commission released its latest Sentinel Event Alert this morning highlighting the need for healthcare facilities and staff to maintain radiation doses as low as possible during diagnostic imaging in order to decrease exposure to repeat doses. The Alert asks healthcare organizations to address contributing factors to eliminate avoidable exposure by weighing the medical necessity of a given level of radiation against the risks.

According to the Alert, the US population’s total radiation exposure has nearly doubled over the past two decades, and  studies have estimated that 29,000 future cancers and 14,500 future deaths could develop due to radiation from the 72 million CT scans performed in the US in 2007.

In response, the Centers for Medicare & Medicaid Services (CMS) will require accreditation of all facilities providing advanced imaging services (CT scans, MRI, PET, nuclear medicine) including non-hospital, freestanding settings beginning January 1, 2012. The state of California is also requiring facilities that furnish CT X-ray services to become accredited by July 1, 2013.

The Joint Commission gives some suggested actions leaders can take to raise awareness among staff and patients of the risk associated with aggregate radiation doses and provide proper testing and dosage through effective processes, safe technology, and a culture of safety.

Click here to download the Sentinel Event Alert and the full list of recommendations.

Joint Commission teams up with ASHI

The Joint Commission and the American Society for Histocompatibility and Immunogenetics (ASHI) have entered a cooperative agreement to recognize histocompatibility (HLA) accreditation. Effective July 1, 2011, ASHI will have the authority as a deemed accreditor for transplant testing services in Joint Commission facilities.

The Joint Commission said the agreement will reduce the burdens on health care organizations by eliminating the need for duplicate laboratory surveys for organizations conducting HLA testing, and will also save them money by accepting the ASHI accreditation as evidence of compliance with Joint Commission policies and standards.

Find out more  and see what each organization has to say about the agreement by visiting The Joint Commission Website here.

Hospitals failing on communication compliance

Two former language-expert hospital administrators in conjunction with Language Line Services have released a new report called “The New Joint Commission Standards for Patient-Centered Care,” that finds hospitals are falling short of The Joint Commission’s language access requirements for patients with limited English.

The requirements were announced in 2009, and  put in place on January 1 of this year, but won’t have an effect on accreditation during the year-long pilot phase.

According to the report and The Joint Commission,  communication breakdowns are the cause for nearly 3,000 deaths every  year, and the majority of these breakdowns involve patients with limited English. Studies show that 50 million people speak a language other than English in the home, and according to the report, some hospitals are not making the connection between language services, patient rights, and patient safety.

The report also says that hospitals may think they are being compliant because they have bilingual staff, contract interpreters, and over-the-phone or video interpreters, but the standards require proof of interpreter training and fluency competence for interpreters in spoken languages as well as American Sign Language  for deaf and hard-of-hearing patients.

The report says hospitals that aren’t in compliance with the new regulations could do damage to their reputations and accrue untold expenses.

Visit The Joint Commission’s Hospital, Language, and Culture website for more information.

Joint Commission updates sentinel event statistics

The Joint Commission has updated its website with its latest sentinel event statistics. As of September 30, 2010, the sentinel event database has record of 7,147  sentinel events reviewed by The Joint Commission since its implementation in January 2005. All events were voluntarily reported by Joint Commission accredited organizations, and represent only a small proportion of actual events.

According to the organization’s statistics, the top ten sentinel events submitted to The Joint Commission over the past 15.5 years are:

  1. Wrong-site surgery: 956
  2. Suicide: 832
  3. Operative/post-operative complication: 775
  4. Delay in treatment: 611
  5. Medication error: 563
  6. Patient fall: 461
  7. Unintended retention of foreign body: 421
  8. Assault, rape, or homicide: 270
  9. Perinatal death or loss of function: 229
  10. Patient death or injury in restraints: 204

A total of 7,288 patients were affected by these events, with 4,844 resulting in patient death.

Click here to view more statistics.