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Hospital Safety Center March 2010


March 1, 2010


Bloodborne retains top spot, lockout/tagout spikes

Five precautions to help prevent violence in your ED

Verify fire response plan roles under EC.02.03.01

Review FDA recommendations for CT scanners

Top-cited standard reveals riff with clinical activities

An early look at a new position: Sustainability manager

Keep tabs on proposed humidity range reductions

Preparing for a high-profile forensic patient

When staff members become a security threat


OSHA citations

Bloodborne retains top spot, lockout/tagout spikes

On paper, it looks as though OSHA got tougher on general medical hospitals in fiscal year (FY) 2009 because, in practical terms, the average fine per citation rose 47.1% compared to one year earlier.

But the actual dollar difference between the averages is so small that it probably wouldn’t even register on most hospital ledgers.

So what does OSHA’s top 10 cited standards tell us? Bloodborne pathogens violations continue to be the perennial Achilles’ heel for hospitals, but a few other standards provided surprises (see the full list on p. 3).

Of the total inspections in hospitals during FY09, 71 resulted in 346 citations, a slight increase from 328 in FY08.

The most recent figures come from states overseen by federal OSHA only and cover the period from October 1, 2008, through September 30, 2009.


Dissecting fines issued by OSHA

Penalties assessed against hospitals by inspectors in FY09 totaled $220,324, a 7.3% increase from $204,184 in FY08.

However, the FY08 figure was inflated by a particularly bad asbestos inspection at a hospital that alone led to a $70,000 fine against the facility.

FY09 showed an average fine per inspection of $636.77, which paralleled an average of $622.51 one year earlier. But the FY08 average would have been $432.85 if you took out that single $70,000 fine noted above, which is a more useful comparison. In FY07, the average fine was $410.

To be fair, a difference of $200 for average fines at hospitals between two reporting periods is relatively minor compared to the millions in penalties that OSHA levels against other industries, says Bradford Hammock, partner at Jackson Lewis, LLP, a law firm in Reston, VA, where he heads the workplace safety compliance practice group. Hammock is formerly OSHA’s lead counsel for safety standards.

Although he hasn’t seen a general trend of big fine increases by the agency, there does seem to be more reluctance to settle cases with employers, which suggests OSHA compliance officers have greater support from the agency’s headquarters to be aggressive with enforcement, Hammock says.

Given historical precedent, it’s predictable that the bloodborne pathogens standard (1910.1030) garnered the most citations in hospitals, as it has for at least the past 10 years.

Analyzing other contenders

However, there was a noticeable rise in citations for the electrical systems design standard (1910.303), which jumped to the second most-cited OSHA standard in hospitals in FY09 from seventh place the prior year. And the lockout/tagout standard (1910.147) was No. 3, which is a big jump considering it wasn’t in the top 10 in 2009.

There is a considerable amount of superficial compliance with the bloodborne pathogens standard, which can get you in trouble, Hammock says. For example, some safety managers simply cut and paste their exposure control plan from OSHA’s Web site without tweaking it to their hospitals’ conditions, which means facilities haven’t fully met OSHA’s expectations, he says.

As for the jump in lockout/tagout citations, Hammock chalks it up to general ebbs and flows with compliance in hospitals. He has not heard of inspectors focusing more resources on lockout/tagout enforcement.

Although OSHA provided no details to Briefings on Hospital Safety about why certain standards became compliance challenges in FY09, in general, most hospital inspections occur because of complaints made to OSHA.

“It’s possible that employees are becoming more aware of the OSHA requirements and file complaints as hazards are identified,” an agency spokesperson says.

Focusing on the future

On the horizon for this year is potential action from OSHA stemming from its H1N1 compliance directive, which in part requires hospitals to follow pandemic protection guidelines from the Centers for Disease Control and Prevention.

“With the release of the H1N1 directive on November 20, 2009, there may be an increase in hospital inspections,” the OSHA spokesperson says. (All subscribers can read the full directive by logging on to www.hospitalsafetycenter.com and clicking the Special Reports link in the left column.)

Hammock notes the following other areas that could be of interest to safety officers this year:

  • Congress could approve a safe patient handling bill introduced by U.S. Rep. John Conyers (D-MI) in 2009. If passed, the Conyers bill would direct the secretary of labor, likely through OSHA, to issue a safe patient handling standard. The bill, HR 2381 (see www.thomas.gov), remained in committee at presstime in mid-January. If passed, the bill would be a way for OSHA to get around the restrictions set by lawmakers in 2001 when they rescinded OSHA’s ergonomics standard, says Hammock, who helped develop that standard. (See the September 2009 Briefings on Hospital Safety for full details on the Conyers bill.)
  • The agency has announced that it will seek information in March about a potential airborne transmissible disease standard. There is support within OSHA to move forward with this new regulation, Hammock says.
  • OSHA is scheduled to conduct a review of the bloodborne pathogens standard this year, which would involve seeking public comment on the standard’s effectiveness and whether any changes are warranted.
  • OSHA plans to revise its walking/working surfaces rules (1910, subpart D), which could affect efforts by hospitals to manage slips, trips, and falls by workers.


Preview of the Hospital Safety Center Symposium

Five precautions to help prevent violence in your ED

EDs are more likely to be breeding grounds for violence than other hospital zones because patients often don’t come there voluntarily, which adds up to a potential powder keg. Patients arriving at an ED may be on edge having been hurt in arguments, perhaps are intoxicated or high, or act as aggressors themselves interested in continuing a fight.

“The emergency department is a funnel into your institution,” says Fredrick Roll, MA, CHPA-F, CPP, president of Healthcare Security Consultants, Inc., in Frederick, CO. “Patients coming to the ED don’t really want to be there in the first place. Something has happened to them to bring them to the hospital.”

Undiagnosed psychiatric cases also pose a threat to the 24/7 environment of an ED. Whereas patients with behavioral health issues might have used stand-alone clinics before, the failings of these “doc-in-a-box” settings during the recession have driven more behavioral patients to the ED, Roll says.

Roll will be a featured presenter at the 4th Annual Hospital Safety Center Symposium, which takes place May 6–7 in Las Vegas (go to www.hospitalsafetycenter.com for more details). There, he’ll provide further information on ensuring a secure ED during workplace violence and patient surges.

For the first time, you’ll have the option of attending the Hospital Safety Center Symposium in person or virtually from your office.

Assess patients for possible violence

Annual reviews of security plans and incidents offer hospitals an opportunity to improve the safety of ED workers. Roll offers the following five suggestions for preventing ED violence:

  • Tighten access control. Evaluate every entrance (e.g., entries to treatment rooms, reception areas, and outside entrances), determine whether access should be tightened to each, and, if so, when and how. Also consider whether receptionists and intake nurses should be protected with glass barriers or other measures.
  • Evaluate lockdown protocols. Know when to initiate an ED lockdown. For example, if a domestic violence victim is brought into the ED and the aggressor is still at large, would that trigger a lockdown?
  • Review employee training. Some physicians and nurses have a fighter pilot mentality toward working in the ED, assuming that violence comes with the territory, Roll says. But fully reporting incidents can help your facility enact prevention measures.
  • Assess patients for violence potential. As part of the intake process, educate nurses and physicians on how to identify a patient’s potential for violence. Talk to the emergency medical technicians and police officers who bring patients in about the circumstances surrounding the injury or condition and enter this information into the patient’s record. Often these details are ignored, Roll says.
  • Evaluate the effectiveness of enhanced measures. Using canines is an example of enhanced security that brings questions. In some urban hospitals, security dogs help keep potentially problematic people in line, Roll says. However, the animals aren’t as welcome in suburban or rural facilities, he has found, because the dogs can worry people coming into an ED.


Joint Commission notebook

Verify fire response plan roles under EC.02.03.01

Make sure to review the steps listed for fire safety plan training under EC.02.03.01, element of performance (EP) 10. Hospital safety managers who don’t pay attention to this EP could run into problems during a survey, said George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission. Mills spoke during a Joint Commission Resources Webcast on December 15, 2009.

Although the Webcast was aimed at managers in critical access hospitals (i.e., small or rural facilities with no more than 25 beds), the tips from the show can apply to regular hospitals because The Joint Commission has the same physical environment expectations for both settings, Mills said.

EC.02.03.01, EP 10, requires the fire response plan to describe the responsibilities of staff members and licensed independent practitioners at and away from a fire’s location.

Specific duties noted include how to:

  • Activate a fire alarm
  • Contain smoke and fire
  • Evacuate to areas of refuge
  • Use a fire extinguisher

That’s not to say staff members must know how to use extinguishers, but rather the fire response plan must detail what employees are expected to do, if anything, with extinguishers. Some hospitals only train certain employees to use such equipment.

Keep tabs on contractor training

During the Webcast, The Joint Commission offered further insight into how to manage contractors working at a hospital.

Review with contractors issues such as their roles in fire response, how they can help with infection control, and life safety compliance through interim life safety measures.

If a contractor is on-site for only a few hours, there may be little oversight necessary in terms of safety provisions. However, for significant projects lasting several days or longer, “training similar to full-time staff may be needed” for contractors, according to material provided during the Webcast.

As always, it is up to the hospital to determine the scope of a contractor’s work and the risks to patient safety. Special attention should be paid to contractors who might perform work that involves penetrating a rated smoke or fire barrier. Unsealed penetrations can lead to findings under a variety of life safety standards.

Confirm proper extension cord use

The Webcast provided the following other EC and life safety tidbits:

  • Extension cords may not be connected to light fixtures in anesthetizing locations and in any patient care areas, as outlined in the 1999 edition of NFPA 99, Healthcare Facilities. Extension cords are allowed in other areas but are not intended as permanent wiring.
  • There are no standards that address supply boxes left on floors. The Joint Commission expects hospitals to conduct risk assessments on these boxes in terms of infection control risks, tripping hazards, and egress route obstructions.
  • The Joint Commission has no specific requirements for managing hazardous drugs. However, the EC standards do point to compliance with various federal regulations, such as OSHA and Environmental Protection Agency rules.


Review FDA recommendations for CT scanners

Patients allegedly received excess radiation from equipment

Safety committee members should read through the FDA’s new interim recommendations on CT scans, given reports that hundreds of patients were allegedly subjected to excess radiation during these procedures.

“While we do not know yet the full scope of the concern, facilities should take reasonable steps to double-check their approach to CT perfusion studies and take special care with these imaging tests,” Jeffrey Shuren, MD, acting director of the FDA’s Center for Devices and Radiological Health, said in a media release.

An initial safety notification was issued by the FDA in October 2009 after learning of 206 patients who had been exposed to excess radiation at Cedars-Sinai Medical Center in Los Angeles over a period of 18 months. Since then, the FDA has identified at least 50 additional patients who were exposed to excess radiation of up to eight times the expected level during their CT perfusion scans.

These cases so far involve more than one manufacturer of CT scanners. The FDA has also received reports of possible excess radiation from other states. Some of these patients reported hair loss or skin redness following their scans.

Based on its investigation, the FDA issued interim recommendations for imaging facilities, radiologists, and radiologic technologists to help prevent additional cases of excess exposure. These recommendations apply to all CT perfusion images, including brain and heart.

The FDA recommends that facilities with CT services take the following actions:

  • Assess whether patients who underwent CT perfusion scans received excess radiation
  • Review radiation dosing protocols for all CT perfusion studies to ensure that the correct dosing is planned for each study
  • Implement quality controls to ensure that dosing protocols are followed every time and the planned amount of radiation is administered
  • Check CT scanner displays to ensure the appropriate radiation level for the patient
  • Ensure that if more than one study is performed on a patient in one imaging session, the radiation dose is adjusted to an appropriate level for each study

Go to http://tinyurl.com/yfcxcxx to read the full FDA alert.

Settings of machines may be culprits

The settings on Cedars-Sinai’s three CT scanners were changed, causing “immediate jeopardy” in a case that the hospital says involved 206 patients who underwent stroke imaging between February 2008 and September 2009, according to a report released in November by California health officials.

The report stated that in February 2008, the scanning parameters of three CT scanners were changed from the manufacturer’s recommended output of 80 kv (the amount of voltage delivered) and 200 mA (milliampere, the duration of the exposure) to 120 kv and “automatic,” meaning the machine determined mA duration, usually in the 500 mA range.

Government asks for manufacturers’ review

The FDA is also working with manufacturers, professional organizations, and state and local public health authorities to investigate the scope of these excess exposures.

The agency has asked manufacturers to review training for users and information provided to healthcare facilities and put into place new surveillance systems to identify problems quickly.

Cedars-Sinai said it has already implemented many of the FDA’s recommendations following an investigation at the medical center.

“The FDA’s recommendations are similar to the policy and procedure changes that Cedars-Sinai implemented in September after it identified that brain perfusion CT scans were unexpectedly producing higher than expected levels of x-ray radiation,” the medical center said in a media release.

California’s Department of Public Health accepted Cedars-Sinai’s policy changes as the medical center’s plan of correction in response to the state’s investigation.

Blame is swirling on errors

It is still not clear who is to blame for the mishap at Cedars-Sinai. Hospital officials previously said they did not want to shift responsibility for the incident to the CT scanner’s manufacturer, GE.

But in its statement, Cedars-Sinai officials said the incident “has raised considerable questions about why the manufacturer-set ‘auto’ mA setting for the brain perfusion CT scan delivered a higher than expected level of x-ray radiation, since ‘auto’ mA settings in CT and other imaging scanners are generally designed to provide the lowest appropriate level of x-ray radiation.”

Cedars-Sinai said that nearby Glendale Adventist Medical Center also “reported a similar problem with GE brain perfusion CT scan equipment where patients received higher than expected levels of x-ray radiation.”

GE has denied culpability in the alleged overexposures, saying, “Due to pending litigation, we cannot comment on that, but again, there were no malfunctions or defects in any of the GE Healthcare equipment involved in the Cedars incident.”

The state’s classification of the event as one involving “immediate jeopardy” means that Cedars-Sinai may be subjected to fines of $25,000–$50,000. Hospital officials have said that about 40% of the 206 patients who received excess doses of radiation either had patches of hair fall out or redness of skin.

Medical center officials also have said that the additional radiation exposure may have made patients more susceptible to cataracts. The hospital has volunteered to pay for any medical expenses caused by conditions related to their overexposures.

Editor’s note: The original version of this article first appeared on HCPro’s HealthLeaders Media Web site. Please go to www.healthleadersmedia.com to read the latest healthcare headlines.

EC standards tie into FDA alert

Regarding the FDA’s new interim recommendations on CT scans, several Joint Commission standards may apply:

  • EC.02.01.01, element of performance (EP) 11, which requires hospitals to respond to recalls and safety notices
  • EC.02.02.01, EP 7, which requires hospitals to minimize risks of using hazardous energy sources, including radiation and x-ray equipment
  • EC.02.04.01, EP 3, which requires hospitals to identify activities for inspecting, testing, and maintaining medical equipment
  • EC.02.04.01, EP 5, which requires hospitals to report incidents in which medical equipment causes serious injury or illness


Survey monitor

Top-cited standard reveals riff with clinical activities

Like many facilities, Massachusetts General Hospital (MGH) in Boston was cited during its Joint Commission survey for having blood pressure equipment, soiled linen carts, and IV poles stored in corridors on three of its units.

The standard in question, LS.02.01.20, was the most cited one in accredited hospitals during the first half of 2009, according to The Joint Commission. LS.02.01.20 requires facilities to maintain their means of egress, and under element of performance (EP) 13, exits must remain clear of obstructions.

MGH constantly tries to focus attention on the problem of corridor clutter, says Robert Castaldo, director of environmental health and safety at MGH. “[Managing this issue well] takes a lot of work. It’s not just an easy issue to be perfect about.”

The Joint Commission surveyed the 900-bed hospital, which has about 50 patient care units, in August 2009.

Nurses primarily focus on patient care

According to Castaldo, problems with some corridor clutter stem from a conflict of interest between Life Safety Code® (LSC) compliance and clinical care duties.

Clinicians often state that they need to have certain items immediately available; thus, they don’t instinctively monitor corridor obstructions the same way a safety officer might.

“They’re focused on patients, so they’re not focused on equipment in the corridor,” Castaldo says.

The Joint Commission allows wheeled items (e.g., computers on wheels and dietary carts) that are in use by workers to remain in a corridor for up to 30 minutes. After that time limit, the item is considered in storage in the corridor, which violates the LSC.

The commission has two exceptions to this rule: Crash carts can remain in corridors for emergency use at all times, and infection control carts can remain outside active isolation rooms until such time as the isolation patient is moved or discharged.

Steps MGH has taken over the years to improve corridor compliance include the following:

  • Offer refresher training for staff members on units in which clutter recurs. “We also listen to the staff and try to understand clearly what issues they’re having” while working together to improve things, Castaldo says.
  • Encourage staff members to call support services if abandoned carts remain in a corridor.
  • Increase the frequency of equipment pickup from support services.
  • Reconfigure space in a unit for more efficient storage.

Unobstructed corridors are only one aspect of fire protection, which also includes sprinkler protection, smoke detection, and 24/7 staffing on patient care units. Given these precautions, it is unlikely that a fire would spread quickly enough to overwhelm a unit, Castaldo says.

However, he fully acknowledges that items blocking corridors could increase evacuation times from a smoke compartment if patient relocation became necessary, and it remains an important issue to manage well.

Fire drill goals fall short

Surveyors also cited MGH for fire drill performance under EC.02.03.03, EP 1, which requires quarterly drills on each shift.

In the third quarter of 2008, staff member participation in fire drills at MGH was 86%, according to The Joint Commission, a figure that led to the finding. The first two quarters of 2009 saw drill compliance rebound to 100%.

MGH’s internal drill participation target is 95%, Castaldo says. In the third quarter of 2008, administrative changes at the hospital resulted in a temporary lapse, he says.

“These drills don’t happen automatically,” Castaldo says. “It takes somebody to quarterback it so it remains on target.” The lesson in the citation is that organizational changes make hospitals vulnerable to compliance blips, and if surveyors find those blips, citations can result, he says.

“When it did slip up in ’08, we were able to recover quickly” because MGH tracks fire drill activity and recognized the issue right away, Castaldo says.

Emergency plan presentation sets the tone

Surveyors reviewed emergency management planning at MGH but didn’t conduct a tabletop drill.

The hospital employs a multidisciplinary approach to emergency management compliance, and the committee members keep their eyes open for related Joint Commission developments. “This group is extremely active and has a lot of energy, and it does an exceptional job at documenting [emergency planning activities],” Castaldo says.

During the survey, the administrative director of the ED showcased the group’s forward-thinking program and how it aligns with the emergency management standards. The director articulated the emergency operations plan well and spoke the language of surveyors, which is a good style for any hospital to consider, Castaldo says.

The group was able to illustrate how MGH ramped up surge planning efforts in reaction to H1N1 swine flu cases in the Boston area, which satisfied surveyors.

Wrapping up with EC concerns

Surveyors also issued citations under the following standards:

  • EC.02.01.01, EP 1 (identify safety and security risks). In one unit’s bathroom, open hand rails on the wall and a ceiling vent with open rings provided opportunities for distraught patients to hang themselves. Environmental rounds did not address this risk.
  • EC.02.03.05, EP 12 (conduct flow tests for standpipe systems every five years). There were three cases in which the standpipe tests weren’t completed.

Hospital posts its survey report for all to read

Massachusetts General Hospital (MGH) in Boston is one of the few facilities that posts its full Joint Commission accreditation report online for all to see and explains the various findings surveyors issue.

“Our leadership feels it’s a healthy thing,” says Robert Castaldo, director of environmental health and safety at the medical center.

Administrators there believe that if the hospital is open about the accreditation challenges it faces, staff members will feel more comfortable offering suggestions and solutions, Castaldo says.

“I think maybe in the past, folks were reluctant to do that,” he says. “Maybe it was a sense we were airing our dirty laundry in public … [But] it’s better to be up front about the challenges you have.”

To view MGH’s report, go to http://qualityandsafety.massgeneral.org, click the Performance Reports tab, and look in the left column.


An early look at a new position: Sustainability manager

Environmental duties begin to bring a need for direct responsibility

Many hospitals have created “green teams” of ecology-minded employees who strategize ways to reduce waste and energy consumption. At its best, such work enhances patient and employee safety and saves money.

Some medical centers have justified the cost, safety, and public relations boosts these green teams yield—so much so that they’re taking it a step further and creating a full-time position for the management of such initiatives, typically called a sustainability officer or sustainability manager.

The movement has spread far enough that several universities now offer degree programs specializing in sustainable business practices.

John Ebers, LEED AP, CEM, sustainable business officer at Metro Health Hospital in Wyoming, MI, graduated from such a program at Aquinas College in Grand Rapids, MI.

Denise Choiniere, RN, BSN, sustainability manager at the University of Maryland Medical Center (UMMC) in Baltimore, started out in healthcare as a nurse, albeit one with a passion for minimizing the ecological footprint of her facility. UMMC required a nurse for the position because the facility planned for the manager to help develop bedside clinical practice changes.

A trio of ultimate goals

Although they come from different backgrounds, Choiniere and Ebers speak of the same “triple bottom line” that is their goal: enriching patient care, increasing environmental benefits, and minimizing costs in the process.

“Sustainability within healthcare is important because of the impact that we have—healthcare being one of the largest consumers of energy and water—and we generate a huge amount of trash, which has a huge environmental impact,” Choiniere says. “Being conscious and aware of how we do business can have a huge impact environmentally and globally if we can pay attention to what we’re doing.”

Purchasing advantages become evident

Choiniere, who reports to the vice president of facilities and the chief nursing officer, says that when someone’s watching and tracking sustainability at the hospital, the payoffs can come in three main areas:

  • Energy conservation. Using less electricity, gas, oil, and water are probably the biggest ways to cut costs and lessen a facility’s ecological footprint. Water savings, in particular, can be gained inside buildings and outside, too, depending on current landscaping practices and the size of the hospital campus.
  • Waste reduction. Safety and facilities managers now take it upon themselves to analyze the ways the hospital generates waste. Sustainability officers have more time and bandwidth to help “sort the trash,” creating systems in which fewer truckloads of red bag waste get hauled away. There are also benefits from general trash reduction (e.g., recycling blue sterile wrap instead of tossing it out).
  • Purchasing practices. Smart purchasing can turn waste into recyclables and cut costs. At UMMC, the DEHP-free IV tubing Choiniere now orders not only removes those potentially unhealthy chemicals from patient care, but is recyclable, whereas the previous tubing wasn’t. Therefore, that tubing purchase incurs no disposal cost, saving about $8,000 per year.


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