Examples of immediate threat to life and safety, Joint Commission style
In my last posting, I talked about when surveyors invoked an immediate threat to life and safety. Let's take a stroll through the list of "threats" we've encountered during client surveys, shall we?
Consider these:
- Lack of master alarms for medical gas systems
- An unreliable fire pump
- Inoperable fire alarm system
- Fire doors throughout the facility not closing and latching
- Penetrations in fire walls not sealed with a fire-rated material
- Main circuit breaker not tested or maintained and raw sewage leaking from pipes in a crawl space beneath a hospital
- Lack of procedures to identify and maintain fire protection (i.e., lack of an effective means to transmit a fire signal to an external point and the responsible person not knowledgeable on the use of the fire alarm system)
- No means of exit in an emergency and lack of implementation of interim life safety measures
I think if I had to give you a piece of advice, it would be to make sure that everyone on your team has a pretty good understanding of how EC issues interrelate and how your organization ensures that all of these working parts come together and result in the safest possible environment for patient, staff members, and visitors.
And staff members may need to articulate this when you’re not around (unless you're planning on no vacations until the next survey--I know I'd be tired).
If your survey will be between now and the end of the year, then start preparing now. If your survey was last week, start now. If your survey won't be until at least 2009, start now. This is one of those things that is not at all well-served by procrastination.
