Adverse Decisions

Has your organization ever gone through an adverse decision, one that led to immediate jeopardy or preliminary denial of accreditation? If you have, then you know that you do not want to experience that again.

Immediate Jeopardy & Preliminary Denial Of Accreditation

Today we are going to discuss another topic of important clinical issues that could lead to an adverse determination – the inappropriate sharing of insulin pens, improper cleaning of glucometers between patients, and the sharing of lancets or lancet holders.

The Joint Commission (TJC) discussed this in their Consistent Interpretation column from their May issue of Perspectives and it is worth bringing up to you again.

They identify six elements of performance observed by their surveyors that to have the potential to either negatively affect patient care or create risk:

• HR.01.05.03, EP 1
• HR.01.06.01, EP 5
• IC.02.01.01, EP 2
• IC.02.02.01, EP 1
• LD.04.01.07, EP 1
• WT.03.01.01, EP 4

The noncompliance implications reminded readers that CMS issued a memo in 2016 requiring state survey agencies to refer any IC breaches that could potentially expose patients to blood or bodily fluids of another to the appropriate state public health authority. They are advising their surveyors to contact the Standards Interpretation Group for an “escalation evaluation.”

For over 15 years, we have followed press announcements about hospitals where insulin pens were shared between patients.  The adverse media and survey attention these organizations have received, along with the deterioration of reputation that results, should make you committed that similar situations will never be allowed to occur in your organization. 

The discussion about glucometer cleaning and lancet use should lead you to the same conclusion about prevention and adherence to the manufacturer’s instructions for cleaning glucometers. You will want to know which ones are FDA approved for single-patient use or for multi-patient use.

We would encourage all readers to carefully review this month’s consistent interpretation column with hospital quality, infection prevention, nursing, and education staff to assess your own risks on these critically important issues.

Patton Healthcare Consulting

If you’re confronted with an adverse decision, including immediate jeopardy and preliminary denial of accreditation, our panel of expert consultants are here to help. Contact us today for any further guidance!