RSSAuthor Archive for Steve MacArthur

Steve MacArthur

Steve MacArthur is a safety consultant based in Bridgewater, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

And yet another Top 10 list…

Recently, ECRI unveiled its list of the Top 10 Healthcare Technology Hazards (here’s an article discussing this topic). And strangely enough, there is at least a couple that I think you will find oh-so-very familiar. Hopefully, you’re already working on the hazards that fall under your jurisdiction (which will vary from organization to organization), but I think it’s never a bad idea to take a look at what the think tanks are identifying (best believe that your favorite regulatory agency—insert name here—is keeping close tabs on groups like ECRI) and plan accordingly. I’m just going to list the hazards as indicated by ECRI, but if anyone out there in radio land has an interest in more in-depth discussion, please let me know and we can do just that. That said, I think these are pretty straightforward.

1)      Alarm hazards

2)     Infusion pump medication errors

3)     CT radiation exposures in pediatric patients

4)     Data integrity failures in EHRs and other health IT systems

5)     Occupational radiation hazards in hybrid ORs

6)     Inadequate reprocessing of endoscopes and surgical instruments

7)     Neglecting change management for network devices and systems

8)     Risks to pediatric patients from “adult” technologies

9)     Robotic surgery complications due to insufficient training

10)   Retained devices and unretrieved fragments

What is a Life Safety Code® deficiency?

One of the time-honored pursuits, mostly as a function of what you can and cannot manage through the plan for improvement (PFI) process, is what exactly constitutes a Life Safety Code® (LSC) deficiency. Just so you know, I used the “exactly” descriptor for a reason—because the definition, while pretty clear (at least to my mind—feel free to disagree) is a fair distance from exact, but read on and maybe it will become a little more clear.

The “secret” to all of this can be found on pp. 24-25 of the 2000 edition of the LSC. Contained on these two pages are the “documents or portions thereof” that “are referenced within this (Life Safety) Code as mandatory requirements and shall be considered part of the requirements of this (Life Safety) Code.” Thus, these requirements include some of the items you’d probably expect to be there: NFPA 10 Standard for Portable Fire Extinguishers, NFPA 13 Standard for the Installation of Sprinkler Systems, NFPA 70 National Electrical Code, NFPA 99 Standard for Health Care Facilities; and maybe some that you wouldn’t necessarily include in the mix, but make sense when you think about it: NFPA 30 Flammable and Combustible Liquids Code, NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition Operations. Not that I usually get into product endorsements, but I think even a casual glance at the list of required elements would point you towards having a subscription to all the NFPA codes—and that’s not getting into the other publications cited as required (ANSI, ASME, UL) because they all have a share in the mandated references. Oh yes, and the final “other” publication mentioned is Webster’s Third New International Dictionary of the English Language, Unabridged; you could probably get into a lot of trouble with that…

Therefore, an LSC deficiency is really any condition or practice that is not compliant with any of the referenced codes (is your head spinning yet?), so you can probably craft a PFI for just about any safety-related hazard. In this world of ever-shrinking operational budgets, the PFI process may become an everyday tool as opposed to the once in a blue moon process it has sometimes been in the past. Remember, if the deficiency can be resolved within 45 days, then you can use your work order system. But if you can’t resolve the deficiency within 45 days (and budget constraints are no doubt going to have a greater impact on that in the future), then the PFI could become your new BFF.

In-house fire alarm testing documentation must include the required elements

When it comes to the Life Safety document review, there is still a fair amount of survey risk exposure and (no surprise) a fair amount of survey findings. EC.02.03.05 is the 6th most frequently cited standard; 44% of the hospitals surveyed in the first six months of 2013 were cited under this standard!

Some of the findings have related to irregularities in the testing process. You have to make sure that your device inventory numbers match up; if you had 50 pull stations last year and 55 pull stations this year in the testing documentation, you had better know why and it better be because you added some pull stations, otherwise it could get ugly. But one thing I’ve seen in a couple of recent surveys (both TJC and in my own practice) is the documentation of fire alarm and sprinkler system testing and maintenance that is performed by in-house staff. A typical one is the weekly fire pump test—pretty much everyone does that one in house. Now, there’s nothing wrong with that, but you have to make sure that the documentation of in-house activities is in compliance with EP 25, which requires the inclusion of the following information:

 

  • Name of the activity
  • Date of the activity
  • Required frequency of the activity
  • Name and contact information, including affiliation, of the person who performed the activity
  • NFPA standard(s) referenced for the activity
  • Results of the activity

In my experience, most folks have the first three pretty well in hand, but sometimes those last three get lost a bit in the shuffle. It might be worth a review of your in-house documentation to make sure you have all the required elements in place.

Pictograms of matchstick men

In our ongoing series (okay, perhaps that’s a rather ambitious descriptor, but there’s been more than one) relative to the upcoming implementation of the changes to OSHA’s Hazard Communication standard, you might find the information regarding the required pictograms helpful in getting your organization’s folks up to speed on what things are going to look like in the future.

The use of the pictograms is not mandated until June 2015, but I think this will improve the communicability of the hazards of products used by staff in the field. Check out the new graphics here.

Spread out! A Stooges primer on cylinder storage

One group of findings that I have seen with increasing frequency in survey reports are those relating to the segregation of stored compressed gas cylinders. Now I think we can agree that the general concept of enforcing the appropriate segregation of cylinders makes some sense. We certainly would not want to put folks in a position where they would have to hunt around for a full cylinder in an emergency—or worse, grab a nearly empty cylinder when responding to an emergency (and yes, I understand everyone’s belief that grabbing a not full cylinder would never happen “in their house,” but I also know that there is a great belief that nothing could ever get into the MRI magnet field, etc. and I know that sometimes the human element doesn’t work exactly as you would prefer).

I’ve seen many different strategies: “full” and “empty” signs on the storage racks or on the walls above the storage racks; racks painted different color (red for the empties, green for the fulls), etc. There is no specifically prescribed method for ensuring appropriate segregation, but I can tell you one thing: if you have locations for full and empty storage in close physical proximity, it is inevitable (in my experience, natch) that the separation will become blurred and you’ll end up with in use or empty cylinders (more on that in a moment) stored in your full rack. I think the strategy that gives you the best shot at compliance is having the storage racks in completely separate spaces (if the room is big enough for separation, that may work, but I’m really talking one room for the fulls and another room for the empties).

One sticking point in this whole magillah is: how do we manage the cylinders that are not full, but not yet empty? Oxygen ain’t cheap and nobody wants to be in the position of returning partially filled cylinders to their vendors—it’s kind of wasteful. So when you come right down to it, we’ve really got three “classes” of cylinders to manage: full cylinders, in-use cylinders, and empty cylinders. But somehow the code doesn’t necessarily capture the in-use cylinders as a specific concept (NFPA 99-1999 4-3.5.2.2 (b)(2) says: “if stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.” (By the way, I think this particular code reference tacitly supports having the full and empty cylinders in separate rooms) But our friends from Chicago (aka The Joint Commission) provide us with a little more specificity; in the December 2012 issue of Perspectives, we find the following passage “(r)acked full cylinders must be segregated from those that have been opened or used (see NFPA 99-1999 4-3.5.2.2.(b)(2)). There should be no confusion for health care personnel who need a cylinder for patient care about which cylinder to select. If empty and full cylinders are comingled in the same rack without clearly separating the two groups, staff might accidentally retrieve a partially full or empty cylinder rather than a full cylinder.”

So, the acid test, so to speak, is keeping the full cylinders separate from “those that have been opened or used). To that point, I think the way to move forward on this is to establish a policy (you might consider a little risk assessment at the front end) that clearly indicates compliance as a function of the full cylinders being in their own location and once a cylinder is used, moves to a location separate from where the full cylinders are stored. That way you can start to measure compliance with your policy as a function of a compliance rate; you collect data during hazard surveillance and safety rounds (maybe even during fire drills). Once you start tracking your compliance rate, even if there happens to be a misplaced cylinder during a survey, you can use the historical compliance data to support clarification of the finding. This is one of those compliance shortfalls that can come up during survey that can almost always be clarified—as long as you know what your compliance rate is over time. Think of it this way, for every cylinder you might find in the wrong spot (or even not properly secured), there was (I hope!) way, way more that are being appropriately managed—that’s the compliance number that you want to track. It will help get you out of survey trouble!

You lift me up!?!

As I wander around the countryside visiting hospitals of all shapes and sizes, there are a few common challenges that seem to give just about everyone fits. And probably among the most common of commonalities is the challenge of managing patient lifting and all the inherent risks of that frequently occurring occurrence (that would be a FOO for you in acronym-land).

At any rate, while catching up on some conversations on one of the safety listservs (this particular listserv focuses on colleges and universities, but there are some healthcare folks in the mix as well) and I found reference to a very interesting article on patient lifting.

The most useful thing about the article (and it’s pretty gosh-darn useful) is that it includes a link to a protocol that can be used (very quickly so it seems) to effectively forecast the patient care and financial impact of patient lifting changes. Now I know from my past experiences that it can be really tough to “sell” the C-suite on avoided future expenses based on a little technology investment in the now. I’m not sure where you all are in relation to this as a focus item, but on the off chance that it might be helpful…

Steak tips, turkey tips, and compliance tips—such a deal!

I’m not entirely certain what to make of this, but I always try to share anything I come across that might prove useful to you folks in the field. Back in July (yes, I know we are now edging towards the wintry portion of our year—we’ve had a lot of stuff to discuss), in one of the regular editions of Joint Commission Online, there was a list of compliance tips for the most frequently cited Life Safety standards.

Nothing wrong with that, as a going concern, but where I kind of got bogged down when I looked at the tips is that they weren’t necessarily in reference to stuff I’ve seen most in the field. All code compliance tidbits, to be sure, but again, not necessarily the type of stuff with which I’ve seen folks struggle.

As an example, the first tip deals with the required clear width of doors to sleeping rooms, egress doors, and doors to diagnostic treatment areas (existing construction must have at least 32 inches of clear width; new construction must have at least 41½ inches of clear width). Now I can think of a few instances in which I’ve encountered doors that were a might on the narrow side, but I’m also thinking door width is driving this particular standard (LS.02.01.20—egress requirements) to be among the most cited in all of survey land? I don’t know, which is why I’m not sure what to make of this. At any rate, make of it what you will—just make sure you grill those tips to your liking.

Equipment disinfection

I suspect that at least some (perhaps even most) of you out there in the listening audience read or heard about the potential exposure of patients to a deadly brain disease (Creutzfeldt-Jakob Disease or CJD—the CDC has more info on CJD. The exposure seems to have come as the result of some specialized neurosurgical equipment that hospitals rent—and it turns out that CJD-contaminated materials are extremely difficult to sterilize/decontaminate effectively using regular processing techniques. So, this ends up being something of a perfect storm of variables that resulted in the potential exposures. And don’t forget that The Joint Commission has also weighed in on the global risks associated with CJD.

Without getting into a lengthy discussion about this particular event, tragic though it may be, the question I’d like you to ponder is relative to all the loaner/rental equipment that passes through our corridors on a daily basis. Who’s really keeping an eye on this process in your hospital? And do you (or someone in your “house”) periodically check to make sure that the process is effectively managing the safety risks involved. When you start parsing it, managing loaner/rental equipment is a fairly complicated process, one that could give a risk manager nightmares. How comfortable are you with the process at your hospital?

Uniformly clean

Reaching in once again to the viewer mailbag, we find a question regarding the laundering of staff uniforms. In this particular instance, this organization is moving from a business casual dress code for medical staff to providing scrubs (three sets each) to promote uniformity of attire (sorry, I couldn’t resist the pun). Now that the decision has been announced, there’s been a little pushback from the soon-to-be scrub-wearing folks as to whether the organization has to launder the scrubs if they become contaminated with blood or OPIM (the plan is for folks to take care of their own laundering).

So, in digging around a bit I found an OSHA interpretation letter that covers the question regarding the laundering of uniforms is raised and includes the following response:

Question 6: Is it permissible for employees to launder personal protective equipment like scrubs or other clothing worn next to the skin at home?

Reply 6: In your inquiry, you correctly note that it is unacceptable for contaminated PPE to be laundered at home by employees. However employees’ uniforms or scrubs which are usually worn in a manner similar to street clothes are generally not intended to be PPE and are, therefore, not expected to be contaminated with blood or OPIM. These would not need to be handled in the same manner as contaminated laundry or contaminated PPE unless the uniforms or scrubs have not been properly protected and become contaminated.

To my way of thinking, if the scrubs were to become contaminated, which would appear to be the result of the scrubs not having been properly protected (I’m reading that as “not wearing appropriate PPE), then the tacit expectation is that they would be handled in the same manner as contaminated laundry or contaminated PPE and since it is inappropriate for PPE to be laundered at home, then provisions would need to be made for the laundering of contaminated scrubs/uniforms. Now, you could certainly put in place safeguards, including the potential for corrective actions, if you have a “run” on folks getting their uniforms contaminated. It’s certainly possible that, from time to time, a uniform might become contaminated, but the proper use of PPE should keep that to a minimum.

How are folks out there in radio land managing scrubs that are used as uniforms (as opposed to being used as PPE)? Are you letting folks take care of their own garments or doing something that’s a little more involved? Always happy to hear what’s going on out there in the field.

And if I can take a moment of your time, I’d like to take this opportunity to remember my late colleague David LaHoda. This is the type of question he loved to answer and I loved helping him help folks out there in the great big world of safety. David, you are missed, my friend!

Do we really hafta?

Recently I received a question from the field regarding whether employers are required to provide antibody testing at the conclusion of the Hepatitis B vaccine administration process. Now, this is an interesting one in that the guidance is a wee bit circuitous, but I think we can navigate the murk and arrive at a point that makes things somewhat more clear.

In looking at what OSHA has to say about the Hepatitis B vaccine (you can find the OSHA Fact Sheet here), it only mentions the antibody testing in the context of pre-screening employees to see if they need the vaccine (employers are not required to provide the antibody testing as a means of pre-screening, so if new employees don’t know if they have the antibodies, they would have to have the testing done on their own). However, the Fact Sheet indicates that the vaccine must be administered in accordance with the recommendations of the United States Public Health Service (USPHS) that are current at the time the procedure takes place. The Fact Sheet goes on to indicate that “To ensure immunity, it is important for individuals to complete the entire course of vaccination contained in the USPHS recommendations.”

That sends us off to find the USPHS recommendations. A quick search of the Web takes us back in time to June 2001 when the USPHS recommendations were last updated. In the recommendations of the USPHS, while there is not a specific mandate regarding the antibody testing, it is recommended that the testing occur: “HCP who have contact with patients or blood and are at ongoing risk for percutaneous injuries should be tested 1-2 months after completion of the 3-dose vaccination series for anti-HBs.” So, we have USPHS saying the testing “should” happen and we have OSHA saying that the vaccine “must” be administered in accordance with the USPHS recommendations. To my way of thinking (putting my occupational safety/risk management hat on), while the antibody testing is not specifically mandated by OSHA, they mandate administering the vaccine in accordance with the USPHS recommendations, which recommend antibody testing. Again, somewhat circuitous, but I feel very strongly that failing to administer the antibody testing in accordance with the USPHS recommendations would not pass the compliance test with an OSHA inspector.