The ECRI Institute has published its 2017 list of top patient safety hazards and concerns. The Institute publishes the list to highlight and educate healthcare workers on various dangers affecting patients. The list includes guidance on how to effectively respond to these concerns, along with implementing priorities and corrective action plans. This year the list includes:
1. Information Management in electronic health records (EHR)
2. Unrecognized patient deterioration (UPD)
3. Implementation and use of clinical decision support
4. Test result reporting and follow-up
5. Antimicrobial stewardship
6. Patient identification
7. Opioid administration and monitoring in acute care
8. Behavioral health issues in non-behavioral-health settings
9. Management of new oral anticoagulants
10. Inadequate organization systems or processes to improve safety and quality
“The 10 patient safety concerns listed in our report are very real,” Catherine Pusey, RN, ECRI associate director told HealthLeaders. “They are causing harm (often serious harm) to real people.”
The proper use and timely access to EHRs for patient information management was the main concern this year, Lorraine B. Possanza, program director for ECRI’s Partnership for Health IT Patient Safety said in a press release. She says the vast storehouses of patient data now available to physicians have created new challenges.
“The object is still for people to have the information that they need to make the best clinical decision,” she wrote. “Health information needs to be clear, accurate, up-to-date, readily available, and easily accessible.”
The second concern, UPD, has recently been the subject of increased training, education, better clinical protocols, and public awareness campaigns. However, despite faster recognition and response, UPD is still a major concern.
“People have seen how well the campaigns have worked for stroke and STEMI and how much they’ve improved outcomes,” Patricia N. Neumann, RN, ECRI senior patient safety analyst and consultant told HealthLeaders. “What if those same principles could be applied to other conditions that require fast recognition and management? We could have a big impact on improving outcomes.”
Read more at HealthLeaders Media
The Agency of Healthcare Research and Quality (AHRQ) reports that the number of patients sent to the emergency department (ED) for suicidal thoughts has doubled. As of 2013, 1% of all ED visits are related to suicide ideation, which is up from 0.4% in 2006. This is an average increase of 12% annually.
Of the 1% brought in for suicidal thoughts, more than 71% were admitted to the same hospital or transferred to another facility. ED patients with suicidal thoughts often had these behavioral health conditions:
- Mood disorders
- Substance-related disorders
- Alcohol-related disorders
- Anxiety disorders
- Schizophrenia and other psychotic disorders
Visit HealthLeaders Media for more details. And read more on our previous coverage of suicide ideation and prevention.
Due to the adoption of the SAFER Matrix, The Joint Commission announced that it was discontinuing its post-survey measures of success (MOS) process. However, the accreditor clarified that the sentinel event MOS process is still in effect and unchanged.
The Joint Commission has eliminated its post-survey category of “Contingent Accreditation.” Now organizations can only receive one of four decisions: Accredited, Accredited with Follow-up Survey, Preliminary Denial of Accreditation, or Denial of Accreditation.
Accreditation— Given to a facility that’s compliant with all applicable standards or has successfully addressed all Requirements for Improvement (RFI). Once the Evidence of Standards Compliance (ESC) is submitted, the organization will get a notice of full accreditation. Follow-up surveys must be done within six months to show that an organization is compliant with their ESC.
Accreditation with follow-up survey— Given to a facility that isn’t in compliance with specific standards that require a follow-up survey within 30 days to six months. Also requires that problem areas listed in an ESC submission are corrected. Once the ESC is submitted, the organization will get a notice of full accreditation. Follow-up surveys must be done within six months to show that an organization is compliant with their ESC.
Preliminary denial of accreditation— Given to a facility when there’s evidence of one or more of the following:
• An immediate threat to health or safety to patients or the public
• Falsified documents or misrepresented information was given to surveyors
• The facility is missing a required license or certification
• The facility is significantly out of compliance with Joint Commission standards
Additional rules for receiving a “Preliminary Denial of Accreditation” ranking have been listed in the “important updates” section of Joint Commission Connect and are as follows:
• Failing to fix all Requirements for Improvement (RFI) after two opportunities to submit ESCs have passed
• Failing a second Medicare Deficiency Survey for not meeting a Condition of Participation or a Condition Level Deficiency
• Evidence reveals patients have been put in jeopardy due to potential fraud or abuse committed by the organization
A Preliminary Denial of Accreditation (PDA 02) decision is made; organizations are now expected to submit a Plan of Correction (POC) within 10 business days of the final report’s posting. After which, there’ll be a survey within two months to validate the implementation of the POC. This will be done in lieu of submitting ESC within 60 days.
For PDAs, facilities can appeal The Joint Commission to review this decision.
Denial of accreditation - A facility is completely denied accreditation. This happens when a facility:
• Doesn’t to pay its survey or annual fees
• Refuses to let The Joint Commission conduct a survey
• Fails to address the conditions of their Accreditation with Follow-up Survey status
• Fails to submit an ESC
At this point, there are no more appeals or reviews that a facility can use to stay accredited.
Finally, The Joint Commission’s governance structure has changed. Now, decisions on accreditation matters will be made by an executive team rather than an Accreditation Committee. The executive team is now in charge of making accreditation decisions, considering survey reports, follow-up activities, staff recommendations, and any unusual problems raised by the organization seeking accreditation.
Check out Briefings on Accreditation and Quality to learn more about the importance of avoiding denial of accreditation.
Starting March 6, The Joint Commission will send email notifications to organizations about upcoming surveys/review events. For each event, The Joint Commission will post the letter of introduction, the survey/review agenda, and surveyor/reviewer biographies and photos on organizations’ Joint Commission Connect extranet site. Afterwards, an email will be sent to the CEO and contact person for the accreditation team, letting them know this information is now up on the extranet to view. The main difference is how far in advance notifications are sent:
- Announced events—30 days in advance, plus a second email the day of the event
- Short-notice Events—7 business days in advance, plus a second email the day of event
- Unannounced events (including all Medicare certification events)—Same day as the event
Additional information about the different types of events can be found in “The Accreditation Process” (ACC) chapter or “The Joint Commission Certification Process” chapter.
The Joint Commission announced that as of March 1, its surveyors will place special focus on suicide, self-harm, and ligature observations in psychiatric hospitals and units. Now, surveyors will document any and all observations of ligature or self-harm risks in the environment during the survey. Each observation will be documented, classified as a requirement for improvement, scored at EC 02.06.01 element of performance 1, and placed on the facility’s SAFER Matrix.
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 firstname.lastname@example.org.
Home care pharmacies: Cynthia Cook, 630-792-5121 or email@example.com
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.