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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.

Nurses outraged over emergency room security switch up

A change in emergency room security staff has nurses up in arms at St. Josephs Hospital in St. Paul, MN. The hospital has replaced off-duty police officers on the night shift with security guards, reports

The hospital’s nurses union says hospital workers are put at risk by this change. The hospital says that switching is perfectly safe and hospital security guards work longer shifts than off-duty police officers. Off-duty police officers will still secure the emergency room Thursday, Friday, and Saturday nights.

How do you think the hospital should handle the nurse’s opposition? Is this an issue of worker safety if the hospital still employs security guards? Let us know in our comment section.

Patient dies at Napa State Hospital from alleged attack

A patient died April 11 at Napa (CA) State Hospital, Napa while being subdued after attacking a fellow patient.

This event comes after a string of security issues at Napa State Hospital.

The incident, which occurred in a high security area of the hospital, has staff worried about how patients will respond, according to KGO-TV of San Francisco.

Kathleen Thomas-Morris, a Service Employees International Union steward, told KGO that patients and staff are scared of what might happen because of the death of a patient.

An autopsy was scheduled for April 13 because it was unclear how the patient died.

How do you think Napa State Hospital should be handling these ongoing situations? Let us know in our comment section.

Mac’s Safety Space: Crash carts

Q: Is there a regulation that states you can’t store crash carts behind locked doors? We have kept our crash carts in our clean holding rooms for as long as I can remember. We had a Joint Commission consultant tell us we could not store them behind locked doors.

Steve MacArthur: Unfortunately, there are any number of consultants who get too involved in “thou shalts” and “thou shalt nots.” The fact of the matter is there is no standard or performance element that specifically prohibits any particular practice. When you look at the medication management standards–and just to be clear, the only reason we have to take extra precautions is because of the medications in the crash carts–the “requirement” is limited to:

MM.03.01.01, EP 6 – Unauthorized individuals are prevented from obtaining medications in accordance with hospital policy, law, and regulation.

And that’s all there is from The Joint Commission, as far as the standards go, but there is additional information in the FAQ section of the Joint Commission website that provides some instruction in how it would expect an organization to implement a risk strategy based on the requirement. This FAQ refers to medications in anesthesia carts, but I think there are more than enough parallels to be able to extend this to crash carts: (Here is the link to the webpage)

Where the rubber meets the road, so to speak, in your situation depends very much on who has access to the clean holding room (I’m going to intuit that the clean holding room is in a location that would not be considered to be under constant observation, which I suspect is the vulnerability identified by your consultant).

Say someone from materials, when dropping off supplies, would have unobserved, unfettered access to the crash cart–the plastic lock would tell you that someone had gotten in, but remember, the standard requires you to prevent unauthorized people from accessing medications. Securing something effectively is not the same as being able to tell whether someone had actually gained access. But that does not mean that you can’t, under any circumstances, store the crash cart in the clean holding room.

You have to ensure that there is an effective means of preventing someone from accessing the medications without compromising the requirements of MM.03.01.03, EP 2, which requires hospitals to make emergency medications and their associated supplies readily accessible in patient care areas. Most facilities have done this by placing the carts in very close proximity to the nurses’ station, but in clear line of sight.

Ultimately, it becomes an assessment with one axis representing the continuum of least secure to most secure, and the other axis representing the continuum of least accessible to most accessible. Somewhere in that matrix is a strategy in which the medications are sufficiently secure and sufficiently accessible. If you can demonstrate that your current practice meets those criteria, then you should be able to defend your strategy during a survey.

Fear of radiation exposure cause pediatric clinic relocation

Employee concern about possible radiation exposure from the radiology department has prompted Sutter Amador Hospital, Jackson, CA, to temporarily relocate its pediatric clinic.

Clinic employees expressed their concerns about potential radiation exposure and recent health issues to hospital officials, but hospital spokeswoman, Jody Boetzer, told The Sacramento Bee that she couldn’t confirm those health issues.

Sutter Amador Hospital hired an independent health physicist to perform a full risk assessment of the building to test it for radiation. The final report is expected to be delivered by the end of this week. The health physicist also performed radiation testing on March 30 in the radiology department and in the pediatric clinic, but found readings to be normal, reports The Sacramento Bee.

How does your facility handle fears of radiation exposure? What is your plan of action?

Mac’s Safety Space: Greetings From the Survey Zone…

A few items have been popping up in surveys over the last couple of weeks; two require a homework assignment for you, the other I offer as general information. So here goes:

LS.01.02.01 – I thought this one would have gone away forever, but it would seem that there have been a few folks who have lost sight of a very important aspect of the Interim Life Safety Standards and that is the practical application of the risk assessment to determine whether or not the LSC deficiencies you are managing as plan for improvements (PFI’s) (and that’s anything that you are measuring as a PFI) require implementation of any Interim Life Safety Measures (ILSM). Now, every once in a while I get some pushback from folks because this requirement is not necessarily the most explicit in the world; a point with which I do not totally disagree. The key concept here is the phrase “covers situations when Life Safety Code deficiencies cannot be immediately corrected.” I think you’ll agree with me that anything you are managing as a PFI is a deficiency that cannot be immediately corrected, and the surveyors recognize this very clearly. So, homework assignment #1: make sure you have an ILSM assessment for your PFI’s. Pretty simple, so done, done, and on to the next one…

LS.02.01.20 EP #1 – Doors are unlocked in the direction of egress. Now I’m sure you’re all up to snuff on delayed egress doors and the like, but this one is a little, if you’ll excuse the use of the term, funky. Every once in a while, there are exterior doors (and even more rare, interior doors) that have dead bolt locking mechanisms on them. I’ve seen ‘em, you’ve seen ‘em, they are definitely out there. However, if you have dead bolt locking mechanisms on any of the doors in any of your egress paths, you need to make sure that the breakaway features of those doors will still work if the deadbolt is engaged. While this is valuable from a survey standpoint, it makes a great deal of sense to ensure folks can get out in an emergency—and some dead bolt locking arrangements will prevent folks from doing that. So, homework assignment #2: go check all your perimeter doors (and keep an eye out on the interior egress route doors, you don’t want to lock folks in there either).

The information you may very well have figured out—there are more survey days for the LSC surveyors, so they have more time to find stuff and they are finding more stuff. They have more time to look at documents, more time to find penetrations, more time to find corridor clutter, more time to find doors that don’t close and latch, more time to ask to see the ILSM assessments for your PFIs. I do know of at least one survey in which the LSC surveyor arrived a week or so after the rest of the survey team; I don’t know if we should consider that an anomaly or if there are already some scheduling challenges in the mix. Much too early to tell. But if I hear anything more on that point, I’ll be sure to share.

Ok – now get to that homework!