- Mac's Safety Space - http://blogs.hcpro.com/hospitalsafety -

How does your escort service measure up? Hope you’re not letting things get too hot…

I know we’ve (at least sort of) talked about this before (for those of you who might need some thought refreshment in that count or if you’re new to the conversation, see this previous post [1]), but there are still some findings being generated during Joint Commission surveys this year, so I figured it might be worthwhile revisiting one aspect of the whole nuclear medicine security issue.

Let me preface things by noting that I don’t believe that there have been too many instances (a number that approaches zero) in which nuclear medicine deliveries to hospitals have been diverted or otherwise redirected for nefarious purposes. That said, there are certain provisions in the regulations regarding radiation safety and controls programs in healthcare that require couriers delivering nuclear materials to your hot lab (presuming you have one) to be escorted when they are in the hot lab. Unfortunately, if you are interested in finding out what the deal might be for you, the first point to keep in mind is that some states (a handful or so) administer their radiation control programs in accordance with the Nuclear Regulatory Commission (NRC) statutes which do require the escort into the hot lab. But (and isn’t there always a “but”?), there are a great many other states that have an “agreement” with the NRC that allows them to pretty much make their own way (to see where your state figures into the equation, this [2] would be a good place to start) in this regard.

Now the good survey folks from our friends at TJC know about the requirement for escorting the couriers, but they are not necessarily conversant with the requirements for the agreement states—and some of the agreement states do not specifically require the escorting of the couriers into the hot lab. So you need to know (yes, another in the long list of things you need to “know”) what the requirements are in your state, so if it does come up in survey (and it is coming up with increasing frequency), you will know where you stand from a compliance standpoint. As a further thought on this coming up as a survey finding, I suspect that you would need to be prepared to show the surveyor(s) the regulatory evidence that you don’t have to do the escort thing, and, if that is not sufficient evidence in the moment (and we’ll discuss how that might happen in a moment), then you will probably need to make full use of the post-survey clarification process.

Now, the reason I suspect that the state regs might not be enough revolves around the general concept of best practices, etc., which are becoming increasingly similar to actual regulations (or so it seems—it might just be my overactive imagination. I think not, but I’m prepared to admit that there is a possibility). To that end, I suggest (and if you’ve been paying any attention over the years I’ve been scribbling this blog, you probably have a good idea where I’m going now—and I certainly wouldn’t want to disappoint) that you conduct a (ta-da!) risk assessment to demonstrate that the levels of security in place are of sufficient robust-ity (I know that’s not a real word, but shouldn’t it oughta be?) that an unescorted courier results in minimal, if any, risk to your organization.

As I look back at this little screed, I’m glad that I did not promise (or otherwise imply) that I was going to be brief. At any rate, make sure you understand the security requirements in your state and make sure that you are poised and ready to educate any surveyors (real or imagined) that might push on your process.