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Keeping Patients Safe

A friend’s hospital recently underwent a visit from the Joint Commission. I was told that JCAHO cited them for the following infractions:

  • Surgilube in the patient’s rooms was expired. After expiration, I’m sure that the Surgilube turns into napalm or some other dangerous chemical so this is a valid concern.
  • There was too much Surgilube in the drawers in the rooms. After all, patients could eat the Surgilube that hadn’t transmogrified into napalm and become deathly ill from Surgilube intoxication.
  • Tongue blades in the drawers had no expiration date. An obvious attempt to circumvent proper patient safety. Everyone knows that the emerald ash borer eggs living in the tongue blade wood mature after a tongue blade’s expiration, eat their way out of the sterile packaging, and wreak havoc on the trees in the community. One of the trees could then fall over, harming a patient.
  • There were shelves containing items that were within 18″ of the ceiling. Nothing can be within 18″ of the ceiling. No one told them why nothing could be within 18″ of the ceiling, but they were cited for having things there anyway. This, of course meant that the hospital is at risk for being decredentialed for not moving shelving, clocks, and reconstructing some door frames to make sure that the doors were not violating this important safety rule.
  • Laundry in the room wasn’t covered.
  • Boxes of copy paper were sitting under the printer on the floor. No paper was allowed to be sitting on the floor. The reason for this was that if the hospital flooded, the wet paper could pose a hazard to patients. Forget that the hospital sits on a relative hill, so that in order for the hospital to flood, it would probably require that a tsunami occur. Forget that the paper is in an area with no patient access. There were computers sitting on the floor which would electrocute everyone if the hospital flooded. There were garbage cans on the floor, the contents of which would turn to sewage if the hospital flooded. Oh, and there were chairs and beds and desks whose legs were touching the floors as well. But only the copy paper was cited as a violation. So the hospital administrators had the poor maintenance guy grab something from the basement on which to set the paper. Now there is an empty drawer sitting on the floor with boxes of paper perched precariously safely on top of it. Next year it will probably be a citation for not having the copy paper high enough off of the floor.
  • Pump bottles of hand sanitizer were hanging on the walls by the doors. Nothing could be hanging on the walls within 12 inches of a door frame. So they had to have the maintenance guys come back up to the ED, pull the pump bottles out of the wall, and re-insert them in a wall far away from the door.
  • Only after the pump bottles were moved did someone then tell them that the hand sanitizer could not be within 6 inches of any outlet – even if the outlet was GFCI (which they all are). Therefore many of the hand sanitizer bottles had to be moved a second time.

But now look at how much safer the environment is for those patients.

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  1. Did they have to close the hospital down to do all of that?

    It’s the only safe way to move a hand sanitiser bottle… just incase.

  2. It just makes you want to throw your hands up. But, alas, I have solutions!!

    1.Remove the surgilube and tell the patients that JCAH said it was hazardous to the them. When the patient sues for mental anguish and pain caused from “no access” to surgilube, they will rethink the idiocy.

    2. Tongue depressors without expiration? Just get you a good old sharpie. Leave the depressors in the original container. Write “date opened….”
    Expires: Upon usage in patient’s mouth!”

    3. Laundry? Where else is it supposed to go?

    4. Computer paper, etc… More stupidness than you can shake a stick at with the more obvious hazards. But that’s what it’s all about for them. Finding the stupid because they can.

    5. Hand Sanitizer…Rubber suction cups for easy access on counter tops or in bathrooms until they make up a new rule for that being unsafe.

    I had an IG inspection of my “Hot Room” for TB culture back in the day. They found zero gigs until the guy doing the inspection quizzed me about the hepa filter in the hood. It wasn’t marked with an “expires” date and it should not have been unless I wanted to sharpie the info on the hood and then get in trouble for defacing gov’t property!!

  3. the 18-inch rule is (allegedly) to allow for sprinklers to work in the event of a fire. If the room is stacked floor-to-ceiling and a fire occurs, the fire might be somewhere where the sprinklers would be blocked.

    I am told of someone whose hospital was cited for this infraction. The individual responsible for the area, when questioned by the inspectors, said (only semi-facetiously) “Well, if it burns long enough, it will fall away from the ceiling and the sprinklers will put it out.” The inspectors were not amused.

  4. I hate to say it, but the paper on ground rule makes sense.

    Floods don’t occur only when the Mississippi gets ornery, they also occur when a clumsy technician thumb-fingers his herbal tea. Or bleeds out after a paper cut refilling the copier. Paper sheafs do absorb remarkable amounts of liquid, and it’s hard to tell unless you look fairly closely.

    Of course, it would make more sense if you actually knew about these details ahead of time, but you can’t have everything.

  5. We had the same problem re: distance from ceiling/floor/etc. By the time you shrink in the room for nothing close to the ceiling/floor/under the sink(dirty, dirty), you’ve now paid >$300 per sq ft for usable space of 1/3 that which was built!

  6. Mr. Deaf Carpenter

    Thank god I’m not a doctor because I have zero tolerance for idiocy. Imagine if that happened to me on a construction job-site! I would have threw the inspector off the site head first with no hard hat then give a hefty fine for not wearing a hard hat.

  7. -Surgilube: It has an expiration date for a reason, I’m sure. Not keeping up with it is irresponsible so I agree with the citation there.

    -Tongue Popsicle sticks: don’t they need an expiration date for when they’re no longer considered sterile? All the medical devices my company makes are sterilized and heat-seal packaged but still have expiration dates.

    -18″ rule…yes so the sprinklers can work properly in case of fire. Although this rule is probably meant for cases of places having entire rooms stacked floor->ceiling with papers and whatnot.

    -Laundry…I can come up with a few justifications for it needing to be covered….ever try finding something that falls into a pile of laundry?

    -Paper on floor…wtf.

    -Hand sanitizer…maybe this rule is because they have to be mounted to a stud and not just drywall. Not sure if it’s code for a stud to be 12 inches from the frame or how it works if the building has I beam metal studs.

    -GFCI outlets…I do know for a fact that you can still be killed if you short yourself in a certain way that wouldn’t trip the GFCI. Although I don’t think hand sanitizer is a significant electrocution risk.

    • I forgot to conclude…you can tell these rules were written by people who have nothing else to do other than coming up with more rules. It’s probably akin to the DSM IV of buildings: try hard enough and you’ll find something wrong or slightly unsafe with everything.

    • “….It has an expiration date for a reason, I’m sure” Probably because JCHAO *said* it had to! That certainly doesn’t mean it has a purpose or logical meaning!

  8. Apply succinylcholine intramuscular injection to JCAHO/TJC personnel any time they attempt to mark something on their clipboards. Repeat as necessary until the problem is solved.

  9. Our hospital has the hand sanitizer right next to the door (< 12in from the frame) so it is easily visible and accessible thus utilized more frequently. JCAHO makes no sense to me sometimes.

  10. Damned if you do, damned if you don’t. For example – that facility added a zillion extra hand sanitizers to cover for a violation at the last inspection (for having exactly one zillion minus one). By adding all those new ones, they’re now violated for having too many, and there’s no way to put as many as are required, “safely”. Well, we could find an area that’s 12″ from a door frame that’s also 6″ from all outlets; we could just stack them one above the other, unless they’re within 18″ of the ceiling and 12″ from the floor. And there are soooooo many hidden policies that you’ll NEVER be able to even monitor for. But really, the tongue depressors and surgilube? Really?

    BUT, just think how SAFE patients will be when they can’t visit the ER because it’s closed d/t continued, irrelevant JCAHO “violations”.

    I can, however, think of many different ways to violate JCAHO personnel and policies, and NONE of them would be “safe”, and none of them would exactly create a “safe patient” environment.

    I’ve never heard of a single hospital or department “pass a JCAHO inspection with flying colors”. I always imagine how many violations there would be if you placed JCAHO personnel in an empty room with no furniture, no purpose, no patients?

    • Quote from “Making Rounds: The official magazinge of Cape Fear Valley Health” Summer 2010, page 1 regarding a JCAHO inspection: “One surveyor who completed a life safety survey ended his session by saying he has: ‘worked with The Joint Commission for seven years… and has never surveyed a hospital of this size and had no findings!'”

      Would this be the exception that proves the rule?

    • “…..think of many different ways to violate JCAHO personnel” I can think of many, that’s why my mgr always makes sure I’m not working when they stop by, or locks me in a closet!

      “….never heard of a single hospital or department “pass a JCAHO inspection with flying colors” ”
      We had one locally, after JCAHO lost their entire survey and had to come back and do it over. The passed with 100%/or no “exceptions”, and took out a full page ad in the local newspaper to lord it over the other hospitals in the area! :D

  11. freaking ridiculous. i am still crying out for all hospitals to revolt against JCAHO, since it is not mandated that a hospital be JCAHO certified.

    less, and less, and less, and less time for patient care

  12. Everyone knows the keeping enough unexpired surgilube in quantities small enough to not be dangerous is a hospital’s highest safety priority.

    You never know when a patient is going to feel like experimenting in the sterile dehumanizing hospital environment in the David Bowie: Major Tom/Ground Control sort of way. Expired lube might be dry to the point of permitting chafing, while excess lube might permit excessive crimes against physics leading to a reenactment of the big bang outside of the area in radiology where such high levels of ionizing radiation are encouraged.

  13. Was JCAHO invented during the Clinton years? I think it’s too old to be created by Obama.

    Anyway, getting the inspector in trouble can be so much fun if you find that their rules violate OTHER rules, like OSHA, union rules or “defacing gov’t property”. But it does take some research.

    • Individual politician’s don’t much matter. The natural law of bureaucracy demands the bureacracy must continually grow. Embrace it.

    • Actually, JCAHO was invented by surgeons because of the poor quality medicine they saw being practiced in hospitals.

      Our surgeons now consider the JCAHO their Frankenstein monster because it tells THEM how to practice medicine.

  14. OMG. I would say just about every one of those violations exist in our ER, we have not one, BUT TWO, hand sanitizers within 12 inches of the door. Surgilube by the boatloads. We’re doomed.

    Its funny, we had a JCAHO visit a year ago and all of this was in place, but no citing.

  15. I worked in a community sliding fee clinic. We were funding by our states DOH. SO we had the DOH requiring us to do certain things for our grant money…and then another part of DOH that does clinic inspections telling us to do the complete opposite. We stopped providing the service in question until they figured it out. I think we gave each inspector each other’s phone number at let them figure it out…

    And it took them MONTHS!!!!!!!
    (they may have even worked in the same building!)

  16. Just wait until there are surveyors who come around and frown upon non-compliant hand lotion. Never mind that the bottles of the good and bad lotion looked 95% the same.
    But larger, more important issues are left untouched.
    Surgilube? Honestly?
    Where I work, we go through that stuff so fast it couldn’t expire. Let alone remain in the rooms long enough to catch a coating of dust. I think our patients steal it.

  17. surely enforcing these things will ensure goal #1… the continued existence of jcaho!

  18. New Hospital that I’m working at has NO laundry in the patient rooms for this reason. If laundry is in a room and not in a closet or otherwise covered, it’s considered contaminated and is supposed to be removed. So, it’s really cool when you need another washcloth to wash Grandma’s butt and you have to run 6 rooms down to grab another (and everything you bring in the room is contaminated, so whatever you take in there has to be thrown).

    I’ve been hearing about the 18 inches rule since I’ve been in healthcare. It’s a fire code thing so the sprinklers can be activated. I think the actual rule is 18 inches from the bottom of the sprinkler.

    Gotta love tongue blade expiration dates though, that’s pretty cool.

  19. Does anyone have a link to an article that shows that JACHO actually improved patient care? I mean actually helped someone get physically better. All they seem to do is make charts bigger and more people run around doing everything but take care of patients.

  20. Does JCAHO cover only hospitals? What about the offices of family doctors?

    • Thankfully they do not cover outpatient private clinics. I did once work for a hopsital owned clinic and we did have these ridiculous inspections.

  21. Surgilube turning into napalm? (Funny!) :)

    I think that happened to me once.(not funny) It really hurts too …napalm in Bajingoland. As a uro pt, I was going in for a followup, but also had presented with a smoldering fire in Bajingoland area (because of having a foley at home for a few days – I think)..then exacerbated with the additional procedure. With emphasis, I even told the uro receptionist …with a full waiting room of people right there ..that I felt like I was on fire after the appointment..twice ..I told her I was on fire.(She didn’t say anything. What could she say? let me get the fire extinguisher? If only.) Napalm hurts ..I’m just saying.

    Although it really wasn’t the surgilube, it was ..well at the risk of TMI ..I’ll stop now.

    WC ..regarding too many surgilubes …what if?

    I think perhaps they were more concerned that some patients gone wild might indulge in surgilube wars (think canned confetti)thus genuinely concerned for your safety (as only JCAHO can be) and for the wayward patients so that injuries could can be avoided.

    Seriously ..out of control, surgilubically slicked up patients, slicked up floors ..every one would be slip slidin everywhere and if security had to grab said out of control, surgilubically slicked up patients ..well said patients could become human canon balls…so slippery that the exerted pressure to contain them would actually cause them to fly outward to God knows where if the exam room door happens to be open, spreading the surgilube farther into the ED and well ..I don’t have to describe the scene of utter bedlam if everyone and everything in the ED became slicked up with surgilube. So ..one can only conclude that JCAHO called it right in limiting the number of surgilube tubes in the exam rooms.

    What if?

  22. For those blaming JCAH on a political group, it was created in 1951. Few in the health care profession would deny it’s somewhat out of control. I have a copy of their monograph on “Measuring Hand Hygeine Performance”, which one would think could be condensed down into a couple of pages. It is 204 pages long.

  23. I recently found out that our local fire department gave our university’s hospital a ridiculously hard time over hand sanitizer. They claimed it was flammable and would not allow it installed on ANY wall. Eventually they got the fire marshall to relent, but there are still large restrictions on how much of the stuff can be in one location, which drives the medical suppliers nuts.

    I also had some fun with handgel this weekend. My wife gave birth and someone installed regular soap instead of the gel in our room’s dispenser. It was fun to watch the doctors/nurses squirt some on their hands, smell it, and then go Eww (I eventually found a maintenance worker and had it swapped out).

  24. The tongue blade thing makes a little bit of sense if they are sterile. Just like with bandages, they are only guaranteed to stay sterile for so long while in their packaging (things can work their way in). However the need for 100% sterile tongue blades is a lot less than bandages.

  25. JCAHO is like the TSA of healthcare: any prior incident or theoretical threat can lead to a rule, and no matter how onerous or nonsensical the rule, it will be rigidly and unquestioningly enforced for all time.

  26. I just came across this about how JACHO came about:

    “Ernest Armory Codman (1869-1940)[31] is remembered today mostly as a crusader for the reform of hospital standards, a zealous effort that cost him his position at the Harvard Medical Faculty. Codman graduated from Harvard Medical School in 1895 and subsequently completed his internship at Massachusetts General Hospital. He joined the surgical staff of the hospital and became a member of the Harvard Faculty, but lost his staff privileges there in 1914 when the hospital refused to institute his plan for evaluating the competence of surgeons.

    Basically shunned by his colleagues, Codman was forced to develop his own private hospital in order to test his management concepts. Around the time that he presented his “end result system of hospital standardization,” the American College of Surgeons was founded. The “End Result” System became the stated objective of the College. His work in quality assessment eventually led to the founding of what is now the Joint Commission on Accreditation of Health Care Organizations (JCAHO).

    “Every hospital should follow every patient it treats long enough to determine whether the treatment has been successful, and then to inquire ‘if not, why not’ with a view to preventing similar failures in the future.”

    Codman invented a number of surgical instruments (drill, sponge, vein stripper, wire passing drill), and is remembered for numerous eponyms: Codman’s tumor of connective tissue, Codman’s radiographic triangle in osteosarcoma, Codman’s sign in rupture of the supraspinatus tendon, and Codman’s exercises in shoulder injury.”

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