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Editor’s Choice: Active Shooters in Healthcare Facilities: Your Prevention and Response Plan

September 23, 2015

1:00-2:30 pm EST

Presented by:
Lisa Pryse Terry, CHPA, CPP

Christian M. Lanphere, PhD, FP-C, NRP, CEM

Active shooters and armed violence represent a rapidly growing issue in America’s hospitals and healthcare facilities. These incidents occur on a near-weekly basis, which means it is time to face the fact that they can also happen in your facility.

Don’t wait until it’s too late to develop an emergency response plan! Join HCPro for a live webcast presented by healthcare safety experts Lisa Pryse Terry, CHPA, CPP, and Christian M. Lanphere, PhD, FP-C, NRP, CEM. They will teach participants how to lessen the risk of a violent confrontation and how to prepare facility staff in the event an armed intruder comes through their doors.

For more information and to register for the webcast, click here.

Joint Commission clarifies LS, EC survey process

The Joint Commission has clarified its expectations for the Life Safety (LS) and Environment of Care (EC) portions of its accreditation surveys, according to an article in the August issue of The Joint Commission Perspectives. The accreditor now requires hospitals to have staff available to assist the Life Safety Code® surveyor with document review.

The Joint Commission’s Survey Activity guide has been updated to include an LS and EC document list and review tool, which lists documents the Life Safety Code surveyor will review. The Joint Commission has also revised its sample LS survey agenda to include more detail on what the surveyor will do.

Read the Joint Commission’s revised LS and EC document list and review tool.

FDA urges hospitals to discontinue use of Hospira Symbiq infusion pumps

The FDA issued a safety communication on Friday urging all healthcare facilities to stop using the Hospira Symbiq infusion systems due to potential cybersecurity vulnerabilities. The system may be accessed or “hacked” from outside the hospital’s network. The infusion system is a computerized pump designed for continuous delivery of general infusion therapy for a broad patient population.

“We strongly encourage that healthcare facilities transition to alternative infusion systems, and discontinue use of these pumps,” the FDA says in the report. Both the FDA and the U.S. Department of Homeland Security are aware of vulnerabilities, but as of yet, there have been no reported breaches in security.

Read the safety communication to learn more and for tips on how to disable the system from your network.

Underwear, Tattoos, and Patient Safety

Editor’s note: I thought this article written by my colleague Lena J. Weiner for HealthLeaders Media, was interesting. Please share your thoughts in the comment section below, I’m interested to hear your opinions on this topic.

As one healthcare system lays down the law with strict rules around employee dress — to the point of mandating underwear–it’s worth asking what dress codes are really for.

And is it time to relax them?

Between the influx of new residents straight out of med school and rising summer temperatures, employees mya be baring more than they normally would (or perhaps should). What’s the appropriate dress code policy for your organization?

Earlier this month, Akron, OH-based Summa Health System enacted a particularly restrictive dress code that not only bans visible tattoos and body piercings–which are standards strictures in dress codes–but also lists acceptable hair colors, stipulates that men’s beards be kept shorter than half-inch, requires female employees to wear hosiery with dresses or skirts, and insists that all employees must wear underwear, and that “the color, design, and style [of these garments] not be visible through clothing.”

The policy has drawn objections from some employees and garnered local attention.

Summa Health’s spokesperson, Mike Bernstein, declined my request for an interview, but he sent a statement saying that his organization “[has] a thorough dress code policy in place that is reviewed on a regular basis and updated as needed,” and that “the specific requirements of the policy are designed with the best interests and safety of our patients in mind as well as to ensure the image we portray as an organization is characteristc of our outstanding reputation in the community.” He says the new dress code is representative of the feedback the organization has received from patients.

Decoding the Dress Code

Jennifer Henly, institutional board member at the National Association for Health Care Recruitment and vice president of client services for NAS Recruitment Innovation says that dress codes help organizations convey a desired impression. “I think staff dress codes are really to promote a consistent, professional image throughout the organization,” she says, adding that she believes that most healthcare workers are comfortable with most dress codes.

“Healthcare professionals are there to help their patients feel safe and comfortable, and to provide them care. I think they’ll honor any particular guidelines that are in place.”

But rules regarding employee dress are a contentious topic for some healthcare workers.

Read the full article at




We need your feedback on Briefings on Joint Commission

Last month, we asked you to take a survey about how you use BOJ. You can still take the survey if you haven’t had a chance to already. Click here to take the survey.

As a follow-up, I would like to ask just a few more questions to discuss some potential changes to BOJ. I would love to have a 10-15 minute phone call with you about the potential changes to make sure we are on the right track.

As a thank-you for talking to us, I will be happy to send you a copy of the latest edition of j-mail: Tools for Ongoing Joint Commission Survey Prep, a $155 value.

Please send me an email at if you would like to share your thoughts and take advantage of this offer.

The nuts and bolts of antibiotic stewardship programs

Editor’s note: This article appears in the August issue of Briefings on The Joint Commission.

In our lifetime, the creation and expanded use of antibiotics has allowed for the successful treatment of routine infections and safer surgical procedures. However, there has also been an overuse and, in some cases, misuse of antibiotics in both animals and people. This subsequently led to the rise of antibiotic-resistant infections, which have made the use of antibiotics increasingly less effective.

Last month, the White House convened a special forum on antibiotic stewardship in which more than 150 healthcare organizations, including the Centers for Disease Control and Prevention (CDC) and The Joint Commission, and announced increased efforts to promote effective antibiotic stewardship within healthcare facilities.

There is growing evidence that hospital-based programs dedicated to improving antibiotic use, referred to as antibiotic stewardship programs (ASP), can improve treatment as well as reduce antibiotic-related adverse events, according to a report issued by the CDC last fall. The report, Core Elements of Hospital Antibiotic Stewardship Programs, highlights the needed components for a successful stewardship program.

Currently, California (as of July 1, 2015) is the only state to mandate that all hospitals implement a physician-led ASP. Previously, approximately half of California hospitals had an ASP in place, with additional hospitals planning on starting a program, but financial issues were a barrier. A law, Senate Bill 1311, passed last September, improved on a previous 2006 law and provided specific guidelines to help hospitals move forward.

Read the full article or subscribe to BOJ here.

Due to space considerations in BOJ, we couldn’t include the list of references. The references have been provided below:

CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014,

CDC: Checklist for Core Elements of Hospital Antibiotic Stewardship Programs,

FACT SHEET: Over 150 Animal and Health Stakeholders Join White House Effort to Combat Antibiotic Resistance, The White House, Office of the Press Secretary, June 2, 2015,

California Antimicrobial Stewardship Program Initiative activities:

Accreditation Q & A

This question is based on The Joint Commission’s National Patient Safety Goals (NSPGs).

Question: Name two NPSGs that have been moved into the standards.

Answer: Answers may vary, but any of the following are correct: standardize list of abbreviations, acronyms, symbols and dose designations; patient involvement in their care as a handoff procedure; annual review of look-alike, sound-alike drugs; manage as a sentinel event all identified cases of unanticipated death or major permanent loss of function associated with healthcare-associated infections; reduce the risk of harm from falls; encourage patient involvement in their care as a patient safety strategy; improve recognition and response to changes in patient conditions – staff can ask for additional assistance; Universal Protocol.

Do you have a question you would like us to answer? Send an email to me at and we’ll do our best to answer your question.

Editor’s Note: The above question and answer are from j-Mail 2016 Edition: Tools for Ongoing Joint Commission Survey Prep.

Assessing Nursing Quality and Patient Safety

Interest in using a variety of nursing engagement surveys as a reportable quality indicator is growing

This article, written by Cheryl Clark, appears in the June 2015 issues of HealthLeaders magazine.

Do your hospital’s nurses feel empowered? Are re nurses’ relationships with physicians strong enough that nurses can call out errors or ask questions without fear? Do they think their hospital hires enough nurses with appropriate skills and provides enough resources to provide safe and timely care? Are nurses involved in making policy?

When nurses are surveyed on these and related questions, which they increasingly are, poor scores may indicate troublesome systemic issues that could, directly or indirectly, affect quality of care, even adverse events. A drop in scores can often be tracked down to a specific hospital unit, research has shown. And poor scores may correlate to “nursing sensitive” patient outcomes, such as patient falls, lengths of stay, pressure ulcers, and infections.

Simply put, this measure is asking nurses what they think about the organization for which they work and how well they trust the care they deliver in their work environments.

Read the full article at

Oh no, Mr. Bill!

Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, wrote about the recent OSHA updates of key hazards.

I always view with great interest the weekly missives coming from The Joint Commission’s various house organs, particularly when there’s stuff regarding the management of the physical environment. And one of the more potentially curious/scary “relationships” is that between the good folks in Chicago and the (I shan’t editorialize) folks at the Occupational Safety & Health Administration. They’ve had a nodding acquaintance over the years, but there is evidence in some quarters (I’ve seen a decided uptick in survey findings relating to hazardous materials and waste inventories—as we’ve noted before, a list of your Safety Data Sheets is not going to be enough on its own to satisfy a finding of compliance with the Hazard Communications standard), that concerns relative to occupational health and safety are becoming a target area during Joint Commission surveys.

At any rate, last week, buried in last Wednesday’s action-packed edition of Joint Commission Online, there was an item highlighting the OSHA updates of key hazards for investigators to focus on during healthcare inspections.

Now I can’t imagine that the list of key hazards would come as a surprise to anyone in the field (in case you were wondering, they are: musculoskeletal disorders (MSD) related to patient or resident handling; bloodborne pathogens; workplace violence; tuberculosis; and slips, trips and falls—surprise!), as these are pretty typically the most frequently experienced occupational risks in our industry.

Continue reading this post at Mac’s Safety Space.

Editor’s Choice: Proper GI Scope Disinfection: How to Avoid Becoming a Statistic

Thursday, July 14, 2015

1:00pm-2:30pm EST

Presented by Peggy Prinz Luebbert, MS, (MT)ASCP, CIC, CHSP, CBSPD, and Terry Micheels, MSN, RN, CIC

Patient deaths related to improperly reprocessed endoscopes have hit the national media. If your endoscopes and other diagnostic GI scopes aren’t properly cleaned and disinfected, they can expose future patients to antibiotic-resistant diseases such as carbapenem-resistant Enterobacteriaceae or (CRE) that can kill up to 50% of infected patients.  Don’t let your facility be the next statistic. Join infection control experts Peggy Prinz Luebbert, MS, (MT)ASCP, CIC, CHSP, CBSPD, and Terry Micheels, MSN, RN, CIC, as they discus everything your organization needs to know to ensure proper GI scope disinfection and protect the lives of your patients.  This 90-minute webcast covers the critical steps of high-level disinfection that must be met each and every day. Don’t miss out on this opportunity to ensure your organization complies with requirements set by The Joint Commission and CMS.

Learn more and register for the webcast here.