The Joint Commission today published its newest Sentinel Event Alert (SEA), which addresses the role of leadership in creating a culture of safety, namely that leaders’ first priority is being held accountable for the safety of patients and staff. Leaders are expected to find flaws and gaps in the care process and ensure that they are resolved.
The SEA comes with an infographic on the “11 Tenets of a Safety Culture.”
In the March issue of Perspectives, The Joint Commission announced that it had added 2016’s sentinel event data to its database. There were 824 sentinel events reported to The Joint Commission between January 1 and December 31, 2016. And 81% of those events were submitted voluntarily by the organization that experienced them. The most often reported events were:
- Unintended retention of a foreign object – 120
- Wrong patient, wrong site, or wrong procedure – 104
- Falls – 92
- Suicide – 87
- Delay in treatment – 54
- Other unanticipated events – 47
- Operative/postoperative complication – 45
- Medication error – 33
- Criminal event – 32
- Perinatal death/injury – 23
Readers should note that less than 2% of all sentinel events are reported to The Joint Commission, and these numbers can’t show the actual frequency of these events.
“In 2016 the trend for the most frequently reported sentinel events continued to be unintended retention of foreign objects, ‘wrong-patient, wrong-site, wrong procedure’ events, patient falls, patient suicides, and delays in treatment,” wrote Gerard M. Castro, PhD, MPH, Joint Commission project director, in Perspectives. “These are not new problems to health care, which indicates that organizations continue to struggle with how to prevent them.
As of January 1, all compounding pharmacies are eligible to enroll in The Joint Commission’s new Medication Compounding Certification (MCC) program, including organizations not accredited by The Joint Commission. The accreditor says that the goal of the MCC program is to:
- Ensure pharmacies are compliant with United States Pharmacopeial Convention (USP) and Joint Commission standards
- Reduce the risk and harm stemming from drug compounding
- Uncover and fix problems in existing compounding policies and procedures
- Train personnel on the correct use of PPE and aseptic techniques
- Ensure the physical environment meets guidelines for cleaning and documentation
- Ensure the proper labeling, dating, and sterility of compounded products
In the March edition of The Joint Commission’s Perspectives, the accreditor writes that the program was created in part as a response to national outbreaks from contaminated compounded medicines. The Joint Commission has eligibility requirements and free 90-day access to the MCC standards on its website and in the E-dition® of the Medication Compounding Certification Manual. Their website also will be updated with a list of U.S. states that require compliance with USP General Chapter <795> and USP General Chapter <797>. The MCC standards have also been updated to reflect USP General Chapter <800> Hazardous Drugs—Handling in Healthcare Settings which was reported on previously in the Patient Safety Monitor Journal.
For more information on the certification contact either:
Hospital-based pharmacies: Brian R. Johnson, 630-792-5144 or email@example.com.
Home care pharmacies: Cynthia Cook, 630-792-5121 or firstname.lastname@example.org
The Joint Commission surveyors will now check to see if hospitals are compliant with the Food and Drug Administration’s (FDA) ban on powdered medical gloves. The ban went into effect in January, with the administration citing the powder’s potential to cause severe airway and wound inflammation, granulomas, and post-surgical adhesions in the tissue between internal organs. Powdered latex gloves also carry the risk of allergic reaction in patients. The Joint Commission will now issue citations on the powdered glove ban under LD 04.01.01, element of performance 2.
“This ban is about protecting patients and healthcare professionals from a danger they might not even be aware of,” said Jeffrey Shuren, MD, director of FDA’s Center for Devices and Radiological Health, in a press release. “We take bans very seriously and only take this action when we feel it’s necessary to protect the public health.”
The Joint Commission has updated Sentinel Event Alert, Issue 45: Preventing Violence in the Health Care Setting with new resources:
- Workplace Violence Prevention Resources Portal
- Quick Safety Issue 4: Preparing for active shooter situations, July 2014
- Quick Safety Issue 5: Preventing violent and criminal events, August 2014
In related news, The American Society for Healthcare Risk Management (ASHRM) has released multiple toolkits on how to assess workplace violence risks in healthcare settings. The toolkits also provide guidance and checklists on what to do if violence breaks out and how to protect staff. The toolkits cover five main areas:
- Staff-to-staff violence/harassment
- Physician- or third-party professional-to-staff violence/harassment
- Patient-to-staff violence
- Visitor/family-to-staff violence
- Stranger/nonemployee-to-staff violence
Read Briefings on Accreditation and Quality for more on workplace violence protection.
The Joint Commission announced an update of its “observer” definition in its accreditation and certification manuals. The new definition is meant to clarify the roles of surveyors and reviewer management staff during on-site surveys and reviews.
The new definition can be found under Accreditation Participation Requirement APR.07.01.01 and Certification Participation Requirement (CPR) 10, and goes into effect on July 1, 2017.
According to the new definition, observers will only participate in the survey/review process if they notice a potential finding or observation that they think the surveyor, reviewer, or organization needs to know about. Field directors are not included in this new definition and are still allowed to take part in the survey process.
The Joint Commission has announced additional revisions to its Environment of Care (EC) and Life Safety (LS) chapters. The revisions are meant to bring the accreditor in closer alignment with the National Fire Protection Association’s 2012 Life Safety Code® (LSC). The LSC was adopted by CMS and The Joint Commission last year. The revisions go into effect July 1, 2017 and apply to hospitals, critical access hospitals, ambulatory healthcare centers, home care, and nursing care centers.
At the National Fire Protection Association’s (NFPA) annual conference in June, members will be asked to vote on changes to NFPA 99 and NFPA 101. While CMS and various accreditors recently adopted and implemented the 2012 edition of the NFPA’s Life Safety Code®, the NPFA is currently working on changes to the 2018 edition. The American Society for Healthcare Engineering (ASHE) called to members who are part of the NFPA to take part in the voting process.
“ASHE has been working hard to align all of the various codes and standards to have less overlap, fewer gaps and fewer code conflicts,” wrote Chad Beebe, ASHE’s deputy executive director. “This work doesn’t happen over one code development cycle, however. Aligning the codes is a long process that occurs over several editions. Each code cycle is a chance for negotiations with code development committees to draw the boundary lines between codes to ensure that the codes don’t overlap, which is where most of the conflicts occur. To maintain these boundaries, continuous involvement in the development of the codes and standards is necessary.”
On February 10, the U.S. Senate voted 52 to 47 confirming Rep. Tom Price, MD (R-GA) as the new head of the Department of Health and Human Services (HHS). Price is an orthopedic surgeon and the first physician to head the HHS since the George H.W. Bush administration. He’s known for his opposition to the Affordable Care Act.
Price’s appointment has been highly controversial, in part due to his investments in healthcare companies that could potentially benefit or be harmed by his actions as HHS secretary.
A recent survey of nearly 1,100 physicians revealed a sharp divide in opinions on Price’s appointment; with 46% feeling positive and 42% leaned negative. The survey also revealed that 47% of respondents believe that Price will diminish patients’ ability to access quality care, with 42% who believed the opposite.
To improve medical outcomes in intensive care units, some hospitals are attempting to make units more accessible for patients’ family and caregivers. Allowing patients to have more access to their families have been shown to reduce hospital stays, improve satisfaction, and help prepare patients for post-discharge, according to Giora Netzer, MD, a critical care specialist at the University of Maryland Medical Center (UMMC) in an interview with The Baltimore Sun.
“It’s not just more humane care, it ends up being better healthcare,” Netzer said.
Netzer also helped develop guidelines for the Society of Critical Care Medicinethat give providers strategies to better include family members in patient care. This includes having an “open or flexible” place by the patient’s bed, having a place for family members to sleep, and educating the family as part of clinical care. It also includes giving patients’ family’s mental, emotional, and spiritual support to reduce anxiety, stress, depression, or risk for post-traumatic stress disorder in certain instances.
The UMMC has implemented the guideline recommendations and now offers larger rooms to accommodate family members. The facility eliminated visiting hours and makes social workers available to work with relatives on the discharge instructions. UMMC is also has a pilot program where family members attend medical rounds.