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LHA Trust Funds Reveals 2018 Top Patient Safety Findings

By Emma James-Wilson & Caroline Stegeman
July 25, 2019

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.


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

Do you have questions about risk management at your facility? Please contact one of our Patient Safety Consultants for more information.

Stacie Jenkins, RN, MSN
Sr. Director of Quality and Patient Safety
Allison Rachal, RN-BC
Sr. Patient Safety Consultant
Caroline Stegeman, RN, BSN, MJ, ONC, CPHRM
Sr. Patient Safety Consultant