[Index] [Blog] Perspectives [PR] – (December, Vol 32, #12)

• PR:  Sentinel Event Policy Expanded Beyond Patients  [FYI:JCCAP, JCSC, MDx,LDR, RNx] Perspectives, December 2012, Vol 32, #12, Pg 6

TJC has updated its summary data of reported sentinel event and their related root causes.  Suicide and medication errors continue in the top 10 of reported events while leadership, communication and assessment remain in the top 5 of root causes.

• PR:  Center for Transforming Healthcare Targets Safe Use of Insulin  [FYI:MDx, Phrm, P&T, RNx] Perspectives, December 2012, Vol 32, #12, Pg 7

Diabetes is fairly common (more than 1 in 5) in general hospital patients and not uncommon in psychiatric hospitals.  Unfortunately, errors related to the management of diabetes and use of the high-alert medication, insulin (i.e., glycemic control) are much too common… especially since they are considered preventable.  This latter point is emphasized by CMS, including poor glycemic management, on its 2013 list of 15 hospital-acquired conditions whose additional associate costs it will no longer reimburse.  In this context, TJC’s Center for Transforming Healthcare has launched its 9th project to focus on reducing insulin-related errors.  Once again, Robust Process Improvement (RPI) will be employed to identify root causes and solutions.  These are projected to be published in early 2014.

• PR: CLARIFICATIONS AND EXPECTATIONS: Medical Gases  [FYI:E&M, SFT] Perspectives, December 2012, Vol 32, #12, Pg 9

Most of this article focuses on piped medical gas systems, but there are 3 paragraphs at the end addressing cylinder storage issues. Some key points to keep in mind are:

• To prevent accidental damage to valves and dangerous gas release, all  freestanding cylinders must be stored in a rack, a cart, or other enclosure   
• There can be no more than 300 cu. ft (approx 12 E cylinders) of gas in a smoke compartment or open to the means of egress
• When stored in a protective environment (e.g., ) up to 3,000 cu. ft. (approx 120 E cylinders) of nonflammable medical gasses may be allowed, but there must also be 1-hr fire-rated room construction, ventilation and explosion-proof electrical fixtures.
• When stored outside, a tank surface must not exceed 130°F.
• To prevent confusion in an emergency, open/used cylinders must be kept separate from full/racked cylinders

[Index] [Blog] The Source [TS] (December Vol 10 #12)

• TS: NA  

[Index] [Blog] Environment of Care News [EC] (December Vol 15 #12)

• EC: Top EC, EM, and LS Compliance Issues for the First Half of 2012  [FYI: EOC, E&M, SFT] EC News December 2012, Vol 15, #12, Pg 8

For Behavioral Health Care

15% EC.02.06.01  safe, functional environment.
13% EC.02.01.05 Foster care placement environments are physically safe.

For Hospitals

52% LS.02.01.20 Integrity of the means of egress.
47% LS.02.01.10  Effects of fire, smoke, and heat minimized
40% EC.02.03.05 fire safety equipment/building features maintained.
37% LS.02.01.30 The hospital provides and maintains building
features to protect individuals from the hazards of fire and smoke.
34% LS.02.01.35 Fire extinguishing systems.
33% EC.02.06.01 Safe, functional environment.
29% EC.02.02.01 Managing hazardous materials and waste risks