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Mac’s Safety Space: Meanwhile, on the other side of town…interim gas measures?

One little item that seems to be popping up with increasing regularity is citing deficiencies in medical gas and vacuum testing reports that are not being managed in a demonstrative way. In some instances, folks have been tagged for the amount of time between identification and resolution, others for not having demonstrably managing the risks associated with a delay in resolving something, etc.

Now we’ve certainly had the “you can live and die during a survey based on what your vendors are documenting” discussion before, though that exchange has tended to focus on life safety device testing. This has the appearance of a fairly significant sea change relative to survey findings and I believe that it represents an overall move towards a risk management process that is not unlike the process outlined under the interim life safety measure (ILSM) standard and associated performance elements. Only time will tell as to how this effects the tenor of surveys and survey results, but I would ask you to think about this:

Any time a deficiency (any type of deficiency—doesn’t specifically have to be a life safety deficiency) or otherwise “unsafe” condition cannot be resolved immediately; there is an inherent risk to be managed. That’s just the nature of the beast. And that risk can be fairly variable in terms of its impact on our facilities and occupants, but how do we know if we don’t run it up the ol’ risk assessment flagpole and see if salutes are forthcoming.

Certainly, it is within our purview to prioritize our responses to stuff that needs to get done, but it would seem that if we do not have our t’s crossed and i’s dotted (until our eyes are crossed), we could be at risk for citation for taking too much time to complete our corrective action (yeah, I know, how much is too much?). But I think if we have a solid, documented process for assessing the risk, identifying any interim strategies for minimizing the risks until such time as the condition can be corrected, we can effectively manage the risk involved with a delay, both from an operational standpoint and a survey management standpoint.

At the end of the day (cliché alert), it is our responsibility to ensure that the safety is maintained at an appropriate level (also meaning that it is our responsibility to identify what appropriate looks like) at all times, even when things are not in perfect shape. When things are not in perfect shape, the mission then becomes one of figuring out how we make sure that any gaps are bridged, which effectively means some sort of interim measure (if you look closely, you’ll see the concept of interim measure doesn’t just show up under the ILSM standard – it’s in the emergency power standards, as well as in the emergency management chapter). It is up to us to manage our resources effectively, and sometimes that means that we can’t fix everything right away – and that’s okay.

As long as we make sure that the associated risks are managed just as effectively as we manage those resources. So, keep close tabs on those maintenance and testing documents getting shoved under your door, any one of them could be trouble during survey.

Which reminds me, if your testing vendors are not providing you with a complete summary of any and all deficient findings identified during the testing and maintenance activities, I plead with you to demand this of them. The surveyors now have more than enough time to find that little mission critical device failure buried on page 15 of the testing report and they’re going to ask you what you’re doing about it. If you didn’t get to page 15 in the report, you’re going to end up with some egg on your face and a probably an RFI (Requirement for Improvement), which won’t make anyone happy. A simple executive summary of deficiencies (or, if they didn’t find anything, a simple statement that says “yes, we didn’t find anything”) gives you one place to look and one access point to managing the risks associated with the finding. I know I don’t have time to read through all those reports and I suspect your time can be better spent, but perhaps that’s just me…

No violations found in incident involving heavy equipment that injured two

OSHA found no violations in an incident at Advocate Good Samaritan Hospital in Downers Grove, IL, where a 3,000 pound piece of equipment came crashing down in a maintenance corridor, injuring two workers.

Kathy Webb, an OSHA area director in Aurora, IL, told The Chicago Tribune’s TribLocal of Downers Grove that OSHA will not issue any citations because there are no standards that cover removing air conditioning and heating equipment, which happened to be what fell on top of the men.

OSHA officials looked at the guidelines, as well as accepted industry practices and standards, and could not come to an agreement on the proper way to remove equipment that large.

How do you think OSHA should have handled the situation? Should citations have been issued? Let us know in our comment section.

Mac’s Safety Space: Harvester of Data: Data collection—your pathway to compliance

At this point, if you’ve been managing your environment for any length of time, you know where, what, etc. you are likely to find at any given moment in terms of environmental opportunities—door wedges, unsecured oxygen cylinders, corridor clutter, penetrations, doors that don’t latch, uncovered linen carts, missing refrigerator temperatures, missing actions for out-of-range refrigerator temperatures—the list (well, my list anyways)  is endless.

These are the things that can go wrong during a survey—the 2011 survey year is bringing more eyes for more days—and how long do you think everyone in your organization can be “perfect” (less than perfect will get you loads of citations—ask anyone in your neighborhood who’s been surveyed this year)?

Your responsibility as a safety professional is to manage those imperfections in such a way as to minimize the negative impact of these failure modes (and that’s exactly  what they are, boys and girls) on the safety of the occupants. But how do you know if you’re doing that effectively (a rather good question, wouldn’t you say?)? In the nascent days of performance improvement, it was generally sufficient to know what got improved (or as we say in Boston, “got bettah”), but now things are starting to move in the direction of the next level of paradigm—you can know that something was improved, but the important metric is: How do you know it was improved?

Going back to the endless list at the beginning of this epistle—think of your “heavy hitters,” “frequent flyers,” whatever descriptor you’d like, and ask yourself the question: Has this imperfection moved closer to perfection, and if we think it has, do we have the measurements to back up that assessment?

We collect tons and tons of failure mode data; we issue work orders, we track those work orders, sometimes we make folks come to the EOC Committee to atone for their sins. But do we know what our compliance rate is for any of these opportunities? I certainly hope so, and I’ll tell you why.

In the past, during the post-Joint Commission survey clarification process, you could “audit” your compliance post-survey and use that as the basis for removing citations from the survey, as long as (for the most part—there are always exceptions, like those pesky “A” performance elements) you could demonstrate that you were at a compliance rate of 90% or better and you make the findings go away. Lately, it appears that there has been a shift away from accepting “current” compliance and a shift towards your compliance rate over time.

And so, I exhort you to start using all that data you’re harvesting and start looking at the compliance journey that it represents. Not everything gets better all the time and the closer handle we have when things start to slip-sliding away, we have a fighting chance of intervening before things get ugly.

Infected water system to be replaced in Washington hospital

The water system at Providence Sacred Heart Medical Center in Spokane, WA, will be treated with chlorine in an effort to kill bacteria that can cause Legionnaire’s disease.

Since January, three cases of bacteria have tested positive in patients at the facility. In January, two occurred in patients occupying the same room, and another case occurred in March, reports The Spokesman-Review. All three patients were elderly.

It is a major undertaking for the hospital to clean its water system, reports the paper. Water samples were collected on May 5 and tests will take place in the next two weeks to confirm the bacteria have been killed.

Mac’s Safety Space: Hot! Hot! Hot! (part 1) – Hot Labs

I’m reasonably certain that when you folks are conducting your annual evaluations, you are looking at the content of your plans, hopefully including the list of areas you’ve identified as being security sensitive (for those keeping score, that would be EC.02.01.01, EP 8) and doing at least a quick evaluation of how you are controlling access to and from these areas.

One item that has popped up during recent survey activity is that fabulously intimate setting—the hot lab in Nuclear Medicine (if you don’t provide Nuclear Medicine services at your organization, then this is probably less interesting than it might otherwise be). I know of at least one organization that was cited for not having identified the hot lab as a security sensitive area in their security management plan. Now I don’t disagree conceptually that if any spot in your organization is worthy of such lofty designation, the hot lab would be among your top three or maybe five, but I’m not entirely sure when the decision as to what did or did not merit that designation was given over to others.

Now I believe in this particular case that the failure to specifically identify the hot lab in the security management plan was more an oversight. For those of you working in healthcare for any length of time, the “security” of the hot lab existed long before the concept of security-sensitive showed up in any regulatory standards other than those promulgated through the good graces of the Nuclear Regulatory Commission (and now administered primarily at the state level). Now, I’m not saying that you should add the hot lab to the list if it’s not there (might not be a bad idea—but I’m not in the business of telling you what to do), but what you might want to do is maybe look at the security of the hot lab as a little performance improvement exercise. I’ve found in some hospitals lately that there have been little opportunities relative to managing material deliveries to these areas, changes in work flow, etc., that have benefited from a little look-see.

I think recent events in Japan might result in a little more scrutiny of all things radiological (management of lead PPE, especially in off-site settings not directly controlled by radiology; radiological decontamination, etc.) during Joint Commission surveys. Always better to have responses ready if the question gets asked.

Next week, we’ll look at another hot topic that’s surfaced during recent surveys.

Mac’s Safety Space: Peeling back the layers of the onion—adventures in the kitchen

I cannot honestly say that this has been cropping up in Joint Commission surveys, but it has been enjoying a more prominent position during state survey.  And, since I’ve found that this one is not always uniformly understood, I figure it’s time to toss it out for the group’s consideration.

A year or so ago, a client facility was cited during a state survey with failing to conduct monthly inspections of their kitchen fire suppression system. Now, I will freely admit that my first response was “bull___,” entirely basing that response on what was enumerated in the Joint Commission standards, or, more precisely, what I “thought” was enumerated in the Joint Commission standards. So, journey with me to that most estimable of destinations: EC.02.03.05 EP #13, which says that hospitals must inspect kitchen’s automatic fire-extinguishing systems every six months and they are expected to keep a record of when these inspections are conducted.  There then follows two notes, one fairly straightforward, which says that fire-extinguishing systems do not need to be discharged, but the other is where we head to our next point in the journey: It says to consult NFPA 96, 1998 edition for performing inspection guidance.

OK, National Fire Protection Association (NFPA) 96 – 1998, let’s see what we have there. OK, so there are a couple of different types of systems that are considered (I don’t know that I would go so far as to say “allowed,” but I think we can intuit that much): carbon dioxide, automatic sprinklers, dry chemical, and wet chemical, with installation, etc. being in accordance with the applicable standard. For the purposes of this particular lesson, we turn to the standards associated with dry chemical (NFPA 17) and wet chemical (NFPA 17A) and find this lovely little item (this is in Chapter 9 in NFPA 17 – 1998 and Chapter 5 in NFPA 17A – 1998, but the requirements are identical; I’m using NFPA 17 here):

9-2 Owner’s Inspection

9-2.1 On a monthly basis, inspection shall be conducted in accordance with the manufacturer’s listed installation and maintenance manual or owner’s manual. As a minimum, this “quick check” or inspection shall include verification of the following:

(a) The extinguishing system is in its proper location.

(b) The manual actuators are unobstructed.

(c) The tamper indicators and seals are intact.

(d) The maintenance tag or certificate is in place.

(e) The system shows no physical damage or condition that might prevent operation.

(f) The pressure gauge(s), if provided, is in operable range.

(g) The nozzle blowoff caps, where provided, are intact and undamaged.

(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.

9-2.2 If any deficiencies are found, appropriate corrective action shall be taken immediately.

9-2.3 Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.

9-2.4 At least monthly, the date the inspection is performed and the initials of the person performing  the inspection shall be recorded. The records shall be retained until the next semiannual maintenance.

So, you know the fire extinguisher-type tags that are hanging on your kitchen suppression actuators (or somewhere nearby)—somebody’s supposed to be filling out the monthlies. And guess who would be considered the owner … three guesses and the first two don’t count. Better get a PM started if this was a surprise!

Man accused of murder at Napa State Hospital will go to trial

In the ongoing saga at Napa State Hospital in Napa, CA, following a nurse’s murder by a patient, a judge has ruled that Jess Willard Massey will stand trial for murder.

Massey will be on trial for the murder of nurse Donna Gross on October 23. After speaking with Napa County Sheriff’s Detective Todd Hancock, Massey admitted to the killing, saying he heard voices telling him Gross was the devil, reports the Napa Valley Register.

A hearing will take place June 14. If convicted, Massey faces life in prison without possibility of parole.

New infant security system dubbed Hugs and Kisses

A new infant security system involving ankle straps and monitors has been launched at St. Lucie Medical Center in Port St. Lucie, FL, to ensure infant abductions and mix-ups don’t occur.

Infants born at the hospital will wear ankle straps and a monitor known as a Hugs tag so nurses can track the infants anywhere on the maternity floor, reports An alarm will sound if an infant is moved to an unauthorized zone or if the ankle straps are removed.

Mothers will don a tag—called the Kisses tag—that electronically connects to her baby’s monitor. An alarm will also sound if the mother and baby’s tags don’t match.

Though no specific incident triggered the new alarm system, hospital spokeswoman Ginger King says the organization wanted an extra layer of protection to help parents feel safer.

Check out other infant security system news at Mac’s Safety Space.

How does your facility prevent infant abductions? Let us know in our comment section.

Mac’s Safety Space: Scoping out some changes

Keep an eye out for the forthcoming issue of Briefings on Hospital Safety, which will include a lovely article on the new “requirement” from The Joint Commission regarding the inclusion of flexible and rigid endoscopes through the good graces of your Medical Equipment Management Plan. A quotation-fingered requirement because this one has taken a somewhat circuitous and unusual route to we the people, so a little (hi)story. Stop me if you’ve heard this one …

Historically (or perhaps le mot juste would be “traditionally,” but I digress) Joint Commission requirements show themselves to us in one (or more) of three places: the Comprehensive Accreditation Manuals, the TJC house organ “Perspectives,” or on the FAQ pages of the TJC website (for those of you keeping score, that would be My sense of it was that this was an effort to make the notification more manageable for end users—we should be able to keep track of three venues, one would think.

But lately, it seems that requirement-looking missives are showing up in other venues. While I don’t necessarily like to advertise for other folks, if you haven’t yet signed up for Joint Commission’s e-mail alerts, you definitely should check it out ( Not every issue is a gem from a safety perspective, but there’s more than enough to keep it on your regulation rotation, particularly as there have been some standards change announcements.

Then we have situations like we have with the whole endoscope issue. Association of Medical Instrumentation (AAMI) members have known about this pretty much since George Mills “introduced” this “requirement” at the 2010 AAMI Annual Conference and Exhibition. Now, not being a member of AAMI, I didn’t happen to be there, and since I don’t subscribe to AAMI News, I didn’t happen to see (until recently) the article outlining this new requirement. But there’s definitely been a groundswell of interest among the clinical engineering folks, a mix of consternation and resigned acceptance, so this “story” is breaking out into the mainstream.

But looking at how it’s happened (and by the way, I have no real sense of when this is likely to be specifically enforced during survey. July 1, 2011? January 1, 2012? I searched for “endoscope” on the Joint Commission website and could find no mention relating to the designation as medical equipment), I have to wonder if, until there is something a wee bit more official, this is a sure-fire way to alert people in the field who might have a more than passing interest in such things. I don’t know, and I guess time will tell, but I have to tell you I think I liked things better when there were only three places to keep an eye on.

I’m still not entirely certain that the clinical engineering folks aren’t being tasked with managing a process over which they have little control over the identified failure modes (cross-contamination seems to be more the result of end-user competencies than it would be initial and ongoing preventative maintenance and inspections, but please feel free to disabuse me of that notion…)

Mac’s Safety Space: Transporting blood and urine samples

Q: A question about transporting blood and urine samples. Do the samples need to be in a biohazard bag when transported either by hand, on a cart, or via a tube system that can go both to the lab and the pharmacy?

Steve MacArthur: I think the simple response to your question is yes, based on the requirements in the Bloodborne Pathogens Standard. First off, we start with the section on specimens on OSHA’s website:


Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping.

Now we could certainly discuss the merits of urine as a function of “other potentially infectious materials”, but in these days of Standard Precautions, the assumption we make is that it is presumed infectious until proven otherwise. We could also discuss the merits of the zip lock plastic bag as a function of leakage prevention, which will clearly depend on what the specimen is in; plastic would nominally be OK, while glass is probably a little less safe, depending on the method of transport, which would be another consideration.

So moving on to labeling, it seems pretty clear that some sort of unique identifier is in order and since the “standard” for that would be the biohazard symbol, I think we can safely identify that combination as the way to go.


The container for storage, transport, or shipping shall be labeled or color-coded according to paragraph (g)(1)(i) and closed prior to being stored, transported, or shipped. When a facility utilizes Universal Precautions in the handling of all specimens, the labeling/color-coding of specimens is not necessary provided containers are recognizable as containing specimens. This exemption only applies while such specimens/containers remain within the facility. Labeling or color-coding in accordance with paragraph (g)(1)(i) is required when such specimens/containers leave the facility.

In the interest of full disclosure, I’m including the items under paragraph (g)(1)(i) below, just in case there is something than clicks with your particular situation:


Labels and Signs –




Warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material; and other containers used to store, transport or ship blood or other potentially infectious materials, except as provided in paragraph (g)(1)(i)(E), (F) and (G).


Labels required by this section shall include the following legend:


These labels shall be fluorescent orange or orange-red or predominantly so, with lettering and symbols in a contrasting color.


Labels shall be affixed as close as feasible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal.


Red bags or red containers may be substituted for labels.


Containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clinical use are exempted from the labeling requirements of paragraph (g).


Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal are exempted from the labeling requirement.


Labels required for contaminated equipment shall be in accordance with this paragraph and shall also state which portions of the equipment remain contaminated.


Regulated waste that has been decontaminated need not be labeled or color-coded.

Hopefully, that helps answer your question; I think as long as you have something that is specifically identifiable to all who would be handling the specimens, you should be fine.