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Joint Commission Behavioral Health Update

March 2010    
In This Issue
Assess your Environment of Care for Suicide Risks
Heads Up on Labeling of Multi-Dose Vials
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 
It was a pleasure to see several of you at the National Association of Psychiatric Health Systems Annual Meeting in Washington D.C. earlier this month. It was a very informative meeting and Barrins & Associates was proud to be a sponsor for the event. You may be interested in a study that was presented: The Economic Impact of Inpatient Psychiatric Facilities: A National and State-Level Analysis. Click on NAPHS Economic Analysis  to view the report on the NAPHS website.

This month in our newsletter, we are providing our readers with  information and resources on two Joint Commission requirements that can be challenging. Our first article deals with conducting an assessment of suicide risks in your environment of care. The second article clarifies the current TJC requirements for the labeling of multi-dose vials. 
We value your feedback on the newsletter. Please email us your comments and tell us what topics you would like to see in future issues.  We look forward to hearing from you!  Also, feel free to forward this newsletter to your colleagues. 

Regards,Forward this issue
Anne Barrins
EOC Assessment 2 - LeftAssess your Environment of Care for Suicide Risks
As Joint Commission surveyors conduct tracers during your survey, they are on the look-out for elements in the environment that could create a risk of suicide for your patients. Environmental suicide risks are frequently cited in surveys of psychiatric hospitals, psychiatric units of acute care hospitals, and residential behavioral health programs.
Examples of issues cited  on survey include use of plastic trash can liners, loopable hardware in patient bedrooms and bathrooms, and non-breakaway rods in closets and showers.
When these risks are identified, the organization is typically cited for not having conducted a thorough risk assessment of the environment. The relevant standard is EC.02.01.01 (in both the Hospital and BH manuals):
"The hospital/organization manages safety and security risks."
EP 1: "The hospital/organization identifies safety and security risks associated with the environment of care."
Too often, organizations are unable to demonstrate that they have conducted a formal  risk assessment, analyzed the results and made decisions about how to address the identified risks.  The best way to tackle your risk assessment is to take the following steps: 
  • Select a formal tool that will be used to identify and rate the environmental risks.
  • Convene a team representing both facility managers and clinical managers. (It's helpful to include an objective observer who is not involved in the operation of the unit.)
  • Identify and rate the specific environmental risks.
  • Consider the type of patients that occupy the space.
  • Consider past incidents from your own organization and others you have learned about from the literature.
  • Prioritize the identified risks
  • Make decisions whether to accept, mitigate or avoid each risk. 
  • For the highest risks, develop an action plan based on your assessment.
  • Keep your Safety/EOC Committee informed of your progress and document these updates in your minutes.
Based on our experience in analyzing several sentinel events, we have developed a comprehensive tool that we are glad to share with you. It's a Patient Safety Risk Assessment that addresses both the Physical Environment and the Clinical Environment. Many clients have found it a useful tool for conducting their risk assessment. To receive a copy, email us and type "Risk Assessment Tool' in the subject line. We will email you a copy of the tool.
Another excellent resource is the Design Guide for the Built Environment of Behavioral Health Facilities (Edition 3; updated August 2009) available on the NAPHS (National Association of Psychiatric Health Systems) web site. The guide identifies specific resources for risk reduction products in the behavioral health setting. It can save you a lot of time searching for the right product. Click on Design Guide to view this resource on the NAPHS website.  
Medical Devices 2 - RightHeads Up on Labeling of Multi-Dose Vials
Medication storage is an area where organizations often encounter challenges during Joint Commission surveys. Indeed, medication storage has been one of the top ten most frequently cited standards for several years. One of the medication storage processes  reviewed during surveys (and frequently found non-compliant) is the process for the labeling of multi-dose vials. The most common multi-dose vials in psychiatric hospitals and behavioral health organizations are vials of insulin and PPD solution.
Let's review the current Joint Commission requirement:
Multi-dose vials must be labeled with the expiration date. The relevant Joint Commission standard is as follows:
MM.03.01.01 (same for Hospital and BH): "The hospital/organization safely stores medications."
EP7: "All stored medications and the components used in their preparation are labeled with the contents, expiration date, and any applicable warnings."
(Note: This is a Direct Impact element of performance.)
The expiration date can be based either on the manufacturer's recommendation or on the default expiration date of 28 days established by USP 797 Guidelines (United States Pharmacopeia
The common practice in most organizations is to require that nursing staff mark the vial with the date on which it was opened and then discard any unused content 28 days later.
However, this does not meet the specific requirement of MM.03.01.01 EP 7. Thus, in order to be compliant with this standard, the multi-dose vial must be labeled with the expiration date.  If the default expiration of 28 days is used, then the vial must be labeled with the date that is 28 days later than the open date. For example, if the vial was opened on March 15th, it must be labeled with the expiration date of April 12th.
The standard does not have a requirement to label the multi-dose vial with the date on which it was opened. However, since many organizations already have this practice in place, they are continuing to label the vial with the open date and have now added the expiration date as well.
Other organizations have found that there is not enough space on the small vials to write both the open date and the expiration date and have switched to just the expiration date. Whichever procedure you choose, be sure to do the following to ensure  that the process is consistently followed: 
  • Develop a written policy/procedure regarding labeling of multi-dose vials.
  • Train your nursing staff.
  • Conduct routine audits of your medication rooms to confirm that the vials are appropriately labeled and any expired contents are discarded.
Resource: Be sure to check out the Medication Management BoosterPak recently released by The Joint Commission. It's available on your TJC extranet site (click on The Joint Commission Connect on the TJC home page.) The BoosterPak contains a wealth of information and useful recommendations for tackling challenging medication storage issues. 
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Barrins & Associates provides Joint Commission consulting services for the Behavioral Healthcare industry. Our clients include both psychiatric hospitals and freestanding Behavioral Healthcare organizations. We specialize in providing Survey Preparation and Continuous Survey Readiness services exclusively for the Behavioral Healthcare industry.  Barrins & Associates was founded by Anne Barrins who was a Joint Commission surveyor for 13 years.