LHA Trust Funds Reveals 2018 Top Patient Safety Findings

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Behavioral health security in the Emergency Department and life support equipment readiness top the LHA Trust Funds list of patient safety risk assessment findings for 2018. This information is compiled from annual patient safety risk assessments conducted by our RN Patient Safety Consultants. The elements in the risk assessment evaluate hospital performance compared with regulatory standards, industry trends, high-reliability pathways and best practices.

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1. Behavioral Health Security in the Emergency Department

Findings	Recommendations
ED registration desk is accessible	Enclose the registration desk area
ED department is not secure	Secure the emergency department
Staff are not trained to treat violent patients	Conduct de-escalation training with staff
Behavioral crisis drills are not conducted	Perform mock drills to practice handling crises involving behavioral health patients
Debriefings are not performed	Educate staff about and implement incident debriefings
Panic buttons are limited	Install panic buttons in high-risk areas
Staff are unaware of panic button locations or how to use panic buttons effectively	Educate staff on how and when to use panic buttons

2. Life Support Equipment Readiness

Findings	Recommendations
Cart checks are missing	Ensure carts are secure
Carts are unlocked or dusty	Designate staff to monitor, evaluate and check carts
Supplies are expired
Defibrillators are not charged appropriately
Time stamps are inaccurate

3. Standardized Sepsis Protocols

Findings	Recommendations
Limited hardwired protocols in place	Develop & implement sepsis protocols
	Conduct sepsis protocol training for staff
	Monitor protocol utilization and outcomes

4. Safe Utilization of Sedation Scale & Sedation Protocols

Findings	Recommendations
Lack of standardized sedation scales	Scale/protocol in place
Sedation scale vs. sedation protocol	Conduct sedation scale and protocol education for staff
Sedation protocol in place but not followed	Conduct annual competency of current sedation scale and protocol
	Documentation of support scale/protocol in ED
	Follow sedation protocol

5. Medication Security

Findings	Recommendations
Unsecured meds found Top of med carts Nurses station Computer on wheels Anesthesia carts Supply room drawers	Ensure all meds are secure
	Labeled appropriately