Quality & Patient Safety

Quality & Patient Safety Headlines

  • Talk down: Joint Commission on de-escalation

    At 10 p.m. on May 20, 2018, a patient was transported by the fire department to Loretto Hospital in Chicago and put into a wheelchair in the emergency department. It was a Friday night, and the patient had been brought in for alcohol abuse.

    About an hour later, the patient and a patient care technician (PCT) got into a heated verbal altercation. The patient then got up from his wheelchair and walked toward the PCT. Another staffer tried to stand between the two, but the PCT pushed the patient “very hard.” The patient fell and hit his head on the front of his hospital bed, “causing a deep laceration to the head.”

    CMS later cited the facility for violating the patient’s right to be free from abuse and harassment.

    This case study is one of many similar incidents that can be found on HospitalInspections.org. Put yourself in the shoes of the participants: If you were the PCT in this situation, what would you have done? What if you were the staffer who tried to stop the fight—what would you have done to get the other two to calm down? If your employees had been involved, what do you think they would have done?

  • Depression screening and treatment

    Depression is the leading cause of disability worldwide, and 16.2 million Americans experienced a major depressive episode in 2016. It’s also closely tied to suicidal ideation—a major concern of The Joint Commission and CMS. But despite clear guidelines saying providers should screen for depression and provide follow-up and treatment, it’s the fourth least-reported measure on the Medicaid Adult Core Set. And only seven states report depression screening and follow-up data.

    In the January edition of The Joint Commission Journal on Quality and Patient Safety, a study named “Not Missing the Opportunity: Improving Depression Screening and Follow-Up in a Multicultural Community” was published by Ann M. Schaeffer, DNP, CNM, and Diana Jolles, PhD, CNM, at the Harrisonburg Community Health Center (HCHC) in Virginia. Set in a diverse city in Virginia, researchers showcased ways to overcome cultural and language barriers to depression treatment. The study looked at methods to improve the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach for depression. Originally developed for identifying and treating substance abuse disorders, SBIRT has been successfully applied to other chronic health conditions and has demonstrated improved outcomes for depression.

  • Examine your dialysis space to ensure room to separate infectious patients

    Hemodialysis is one of four areas The Joint Commission (TJC) says it’s increasing focus on during surveys. With this in mind, ensure that your hospital’s hemodialysis patients remain in clear view of staff while undergoing the procedure. In addition, make sure there’s enough space to separate patients with respiratory illnesses, fevers, fecal incontinence, or other infectious conditions.

    That includes a way to care for dialysis patients with hepatitis B completely separate from non–hep B dialysis patients—using a curtain for separation is not enough, warns Kathleen Good, MSN, RN, a former surveyor with TJC and now an associate of Patton Healthcare Consulting, which is based in Naperville, Illinois.

    In a November 7 blog post, Andrew Bland, MD, MBA, MSAP, FAAP, FACP, medical director of TJC’s Division of Healthcare Quality Evaluation, wrote that among other infection control practices for hemodialysis, surveyors will be observing water and dialysate testing, medication storage, preparation and administration, and “patient placement in full view of staff during dialysis treatment.”

    What this means, says Good, is that patients must be observable at all times for their safety. In particular, staff must be able to see “dialysis lines where they are connected to the bovine graft, AV fistula, intrajugular catheter, or Permacath™,” she says. Staff must also be able to hear and see the dialysis machines as patients are undergoing dialysis.

  • Suicide Prevention National Patient Safety Goal updated

    The Joint Commission (TJC) announced revisions to its suicide prevention National Patient Safety Goal (NPSG) November 27. NPSG 15.01.01 now has seven elements of performance (EP), up from three. All the changes are listed in R3 Report 18 and will take effect July 1, 2019. The update applies to all TJC-accredited hospitals and behavioral healthcare organizations.

    The report says the new EPs aim to improve quality and safety of care for patients treated for behavioral health conditions and who are identified as high-risk for suicide. TJC officials say the revised requirements are based on more than a year of research, review, and analysis with multiple panels convened by TJC and representing provider organizations, suicide prevention experts, behavioral facility design experts, and other key stakeholders.

    “The science of suicide prevention has really advanced over the past few years, including better tools for screening, assessment of suicidal ideation, identification of environmental hazards in health care facilities, and methods to prevent suicide after discharge,” said David W. Baker, MD, MPH, FACP, executive vice president of TJC’s Division of Health Care Quality Evaluation, in a release. “We had not updated the NPSG since its original release in 2007. This revised version and the accompanying resource compendium will more robustly support health care organizations in preventing suicide among patients in their care.”

  • Sharp HealthCare: Before the plane crash

    In January 2009, all eyes were on the Hudson River when a plane flying out of New York’s LaGuardia Airport crash-landed in the river after striking a flock of geese. Thanks to fast acting by the pilots, all 155 passengers survived, with few major injuries. Trouble started afterwards, though, because of a communication breakdown between airlines and hospitals.

    After the crash, victims were sent to multiple hospitals in New York and New Jersey. At the request of family and loved ones, US Airways called the hospitals to figure out where each passenger had been sent. However, fear and misunderstanding of HIPAA laws prevented the facilities from revealing that information, causing more distress for people wanting to find their loved ones and see if they were all right.

    The disaster spurred officials at San Diego International Airport (SAN) and local hospitals to join forces to create an emergency preparedness partnership. A year after the crash, SAN and San Diego hospitals were holding regular meetings together, providing training, and developing contact sheets of whom to call should a crisis occur.

  • Remembering Winter Storm Jonas

    Consult your emergency management plan when facing an impending storm, and update this plan with lessons learned after each storm to avoid grappling with problems that may already have solutions. This is just one of the lessons reinforced for hospitals that were impacted by Winter Storm Jonas (aka “Snowzilla”) back in January 2016.

    It’s been a few years since Jonas smothered the East Coast, so here are a few facts to refresh your memory:

    • 14 states received over a foot of snow. Seven of them saw over 30 inches of snowfall, including places like New York’s JFK airport and Allentown, Pennsylvania.
    • West Virginia received 42 inches of snow.
    • At the time, Jonas was the biggest single snowstorm on record for at least six locations.
    • 11 states declared a state of emergency, and 13,000 flights were canceled.
    • More than 80 million people were affected by Jonas, with at least 55 deaths attributed to it.