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February 2014Volume 22Issue No. 2

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Briefings on Hospital Safety

Your trusted source for hospital safety compliance

In the 1993 movie Groundhog Day, Bill Murray plays a miserable television weatherman tasked with delivering the weather report from Punxsutawney, Pa., as the groundhog makes his annual appearance to predict how much winter is left.

Murray’s character gets stuck living the same day over and over again, and we get to see the hilarious results of what happens when redundancy takes over.

To the average person the redundancy of living the same thing every day seems like a nightmare. But to a hospital safety professional, it’s a godsend. Having redundancies in place means there’s less likelihood of things going wrong, and in a hospital that’s a good thing. It means there’s a backup so if something does go wrong, there’s a way to fix it quickly and get back to helping patients.

Unlike the movie character, safety professionals sleep soundly knowing (or hoping) things will work tomorrow the same way they worked today.

“With safety, it is important to have repetition, even if you do not have

Safety experts create their own Groundhog Day with redundanciesExperts reveal their pet peeves, relived day after day despite best efforts to improve

Fatal fire in BaltimoreFire safety protocols are being reevaluated after a patient died in a fire at the University of Maryland Medical Center. Smoking is being blamed for the blaze.

Preparing for a power outageIn this Q&A, safety consultant Steve MacArthur explores what you need to do if the lights go out in your facility.

More violence rattles hospitalsRecent shootings and a knife attack reveal how exposed hospitals are to violence and renew the need for safety protocols.

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50%Several sources estimate that hand washing compliance rates in hospitals linger around 50%.

$30,000The estimated damage caused to a hospital room from a fatal fire at a Baltimore hospital in November.Source: Baltimore Sun.

94A 2011 fire in Kolkata, India, killed 94 people at the Advanced Medical Research Institute Hospital.

www.hospitalsafetycenter.com

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February 2014

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“ We are constantly reminding employees that they are not Superman. A 400-pound patient, even when in a wheelchair, still weighs two to three times what the employee does and moving that much weight is going to harm them.”

Bruce Cunha, RN, MS, COHN-S

Jury convicts man in ohio hospital shootingA jury in early November convicted an Ohio man who said he fatally shot his hospitalized wife out of love because of her debilitated condition that left her unable to speak. John Wise, 68, received a six-year sentence for what he said was a “mercy killing” after tes-tifying that he couldn’t stand to see his wife of 45 years in pain. Police said Wise calmly walked into 65-year-old Barbara Wise’s hospital room on August 4, 2012, and shot her at bed-side. She died the next day. Source: www.CBSnews.com

Hospital explores safety issues with danger drillA hospital in Missouri recently changed things up a bit with a security drill that focused on a disgruntled employee. The drill took place in the evening hours, when staffing levels were lower than normal. The evening staff at Cox Monett Hospital were presented with a scenario that tested their ability to deal with a threatening situation in which a caller phoned in veiled threats and then assaulted a staff member outside. Source: www.monett-times.com

Quick Hits

Briefings on Hospital Safety (ISSN: 1076-5972 [print]; 1535-6817 [online]) is published monthly by HCPro, a division of BLR, 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: Regular $329/year or $592/two years; Platinum $549/year; back issues are available at $25 each. • Briefings on Hospital Safety, P.O. Box 3049, Pea-body, MA 01961-3049. • Copyright © 2014 HCPro. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, outside the subscriber’s facility without prior written consent of HCPro or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscrib-er list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BHS. Mention of products and services does not constitute endorse-ment. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

editorial advisory board

Barbara Bisset, PhD, MS, MPH, rNExecutive DirectorEmergency Services Institute/WakeMed Raleigh, N.C.

Joseph cocciardi, PhD, MS, cSP, cIHExecutive DirectorCocciardi & Associates Mechanicsburg, Pa.

Leo J. DeBobes, MA (oS&H), cSP, cHcM, cPeA, cHeP, cHSP, cSc, eMTAssistant Administrator, Emergency Management/ Regulatory ComplianceStony Brook University Medical Center Stony Brook, N.Y.

elizabeth Di Giacomo-Geffers, rN, MPH, cSHAHealthcare ConsultantDi Giacomo-Geffers and Associates Orange County, Calif.

Zachary Goldfarb, eMT-P, cHSP, ceM, cHePPresidentIncident Management Solutions, Inc. East Meadow, N.Y.

ray W. Moughalian, BS, cHFrMPrincipalSaf-T-Man Methuen, Mass.

Senior Director, Producterin [email protected]

Managing EditorJohn [email protected]

Contributing EditorSteven MacArthurSafety Consultant The Greeley Company Danvers, Mass. [email protected]

John L. Murray Jr., cHMM, cSP, cIHSafety DirectorBaystate Health Springfield, Mass.

Paul Penn, MS, cHeM, cHSPEnMagine/HAZMAT for Healthcare Diamond Springs, Calif.

Lisa B. Pryse, cHPA, cPPODS Security Solutions Richmond, Va.

Dalton Sawyer, MS, cHePDirector, Emergency Prepared-ness and Continuity PlanningUNC Health Care Chapel Hill, N.C.

Steve SchultzCorp. E&O Safety DirectorCape Fear Valley Health System Fayetteville, N.C.

Barry D. Watkins, MBA, MHA, cHSPSenior EC SpecialistCorporate SafetyCarolinas HealthCare System Charlotte, N.C.

Kenneth S. Weinberg, PhD, MScPresidentSafdoc Systems, LLC Stoughton, Mass.

earl Williams, HSPSafety SpecialistBroMenn Healthcare Bloomington, Ill.

This document contains privileged, copyrighted informa-tion. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, any use, disclo-sure, forwarding, copying, or other communication of the contents is prohibited without permission.

from The fieldonline


hcpro.com© 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

February 2014

3

emergency, go to p. yy.’ ”A good backup plan for your emergency plan is to

recognize that by nature, it is a flexible document that is meant to be updated from time to time as more information is obtained and mistakes found.

“I learn from other people’s heartaches and head-aches more than anywhere else,” says Tom Sal-amone, president of Code Enforcement Corporation in Yonkers, N.Y. He recalls that hospitals in New York City had a hard time finding vendors to replen-ish supplies during the response to the 9/11 terror attacks because some had agreements with only one vendor. Plans have been rewritten since then. “I say go three vendors deep. Have the redundancies in place,” Salamone says.

• Training. What good is a plan if your staff doesn’t know how to use it? A good backup is to drill and practice until it becomes second nature. Then take the lessons learned and apply them to the plan and drill again.

“One hospital plan I saw said the shutoff valve for the water was in Building B,” says Salamone. “Well, Building B was knocked down three years ago. You want to make sure they are accurate and effective.”

Another problem, some experts say, is the timing of drills.

“Hospitals like to conduct training and exercises during the weekday shift when hospital leadership and the most staff are at the hospital,” says Binder. “The problem is that most events happen outside of those 40 hours when hospital leadership is likely to be away from the hospital and staffing is lighter. Times for training and exercises should be rotated among all shifts.”

• Electrical backups. It sounds like it should be common sense to almost anybody, but a backup electrical supply should be among the top priorities of an effective hospital emergency plan. Most hos-pitals have emergency generators in case of a power outage, but consider: When an EF-5 tornado hit St. John’s Hospital in Joplin, Mo., on May 22, 2011, the emergency generator was sucked out of the hospi-tal, leaving the destroyed facility with no emergency lighting to help the staff evacuate patients. When floodwaters from Hurricane Sandy inundated New York City last year, emergency generators that were

authority to enforce changes,” says Dan Scungio, MT(ASCP), SLS, a laboratory safety officer for Sentara Healthcare, a multihospital system in the Tidewater region of Virginia. “If others know you are not going away and you are not giving up, it will help with compliance in the long term. However, patience is key as you may need to replay the same scene over and over.”

In celebration of Groundhog Day, we thought it would be interesting to take a look at the redundan-cies that hospital safety officials swear by, and also ask about their pet peeves—the problems that come back to haunt them every year, despite their best effort to get rid of them.

Here we go againAs the movie showed, it’s a good idea to have

redundancies in place:• Having a plan. It’s been said many times, but

a good emergency plan is the key first step to know-ing what to do in an emergency—and who to call to get backup as soon as possible. Most hospitals already have an emergency management plan in place, but many ex-perts say that means nothing if people don’t know how to read them. When writing your facility’s plan, have simplicity in mind.

“Many times hospitals think that a large plan shows they are better prepared,” says Bruce Binder, chief operating officer of Global Vision Consortium in Sacramento, Calif. “In reality, plans should be short and easily understood by staff. Simple plans are more likely to be understood and followed.”

Following the theme of simplicity, many experts say emergency plans are often written for the wrong people, and complicated language can be difficult to understand and follow during a stressful time.

“Write plans for the end user. Think about some-one who is given a responsibility at 2 a.m. and needs to know what to do and how to do it now,” says Paul Penn, president of EnMagine, Inc., an emergency en-vironmental health and safety management organiza-tion in Diamond Springs, Calif. “Minimize narratives, eliminate acronyms, maximize tables, algorithms, and charts. Answer the real questions. On the cover of our emergency plans are two statements: ‘If this is an emergency, go to p. xx. If you are in charge of the



February 2014

any other industry in the United States.“People going in and out of the lab area often refuse

to don a lab coat even though it can protect them while working in that environment,” says Scungio. “It does help to regularly remind folks of the importance of PPE, but it is frustrating when an employee who has had a previous exposure is committing the same error that caused the first incident.”

• The flu shot conundrum. The debate goes on every year about whether healthcare workers should be immunized against the flu to protect their patients. Every year, another state considers adding legislation that makes it a law and job requirement for hospital workers to get the shot. And every year, worker unions take a stance against making it a legal requirement, citing reasons from personal freedoms to health con-cerns. Maybe someday we’ll all come to an agreement, but don’t expect that soon.

“If you talk to anyone in infection control, flu season is the one they would skip if they could,” says Peggy Prinz Luebbert, MS, MT(ASCP), CIC, CHSP, creator of IP-Bootcamp in Omaha, Neb. She’s also president and founder of Healthcare Interventions. “Every year it’s different and it comes back with a dif-ferent face and issue.”

• Hand hygiene. If improper PPE has an evil twin, it’s the issue of hand washing. Despite warn-ings from the CDC and other regulatory agencies that 2 million infections and more than 100,000 deaths can be attributed to improper hand disinfection in the healthcare field, it remains a perennial problem to get doctors, nurses, and other healthcare professionals to wash their hands before and after seeing and treating patients. Hospitals and clinics have tried everything from simple signs with cute characters to “secret shoppers” who look for compliance to electronic com-pliance badges to remind their staff to wash up.

“Compliance is only about 50% across the U.S., and that’s gross,” says Kathy Rooker, owner of Columbus Healthcare & Safety Consultants in Canal Winchester, Ohio. “Patients are becoming consumers, and they have a right to know that the office is clean. Infection control is out of control.”

• Injury prevention. OSHA just released a list of the top 10 worker safety violations, and slips, trips, and falls made the No. 1 spot for at least the second year in

installed in the basements of hospitals were rendered useless.

“If a facility professional is going to baby any equipment, it’s going to be their emergency genera-tors, and they’re going to have a means of acquiring a backup generator in case there is a problem with their main generator,” says safety consultant Steve MacArthur. “You better have a solid backup source, because if it’s a regional event, you may be in competi-tion with other hospitals for those generators and a lot of time it’s the person who shows up first with the closest thing to cash that gets the equipment.”

• Fire protection. Fires are something of a rarity in hospitals, mainly due to the planning that goes into engineering them to be relatively fireproof. For the most part, hospitals are designed in compartments, with fire doors and other materials that allow staff and patients to contain a fire and shelter in place for hours until help can get to them. Still, it takes common sense on the part of humans to make sure the system doesn’t fail in an emergency.

“I am surprised by the number of hospitals that have solved their corridor clutter problem by put-ting stuff in the patient rooms,” says Marge McFarlane, PhD, CHSP, CHFM, HEM, MEP, CHEP, principal of Superior Performance, LLC, in Eau Claire, Wis. “They set up a life safety finding right there.”

The same old song and danceJust like Murray’s Groundhog Day character, there

are warnings a safety officer gives to the people he is charged with protecting every day. Unfortunately, too often these warnings fall on deaf ears, no matter how many times they are said. That’s okay because safety officers are a hardy bunch and will repeat the same warnings tomorrow.

• Personal protective equipment. Among the most repeated warnings that safety experts give out has to be reminding workers to wear personal protective equipment (PPE) in the work environment. Whether it’s eye protection, proper shoes, or gloves to protect against bloodborne pathogens, PPE is one of the least heeded warnings in the healthcare work-place, despite the fact that every year OSHA ranks worker injuries in the healthcare industry higher than



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Power outage checklist



February 2014

a row. Safety experts say getting employees to be care-ful when lifting and transferring patients is a constant pain in the neck that comes back to haunt them year after year.

“We are constantly reminding employees that they are not Superman,” says Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety at Marshfield (Wis.) Clinic. “A 400-pound patient, even when in a wheelchair, still weighs two to three times what the employee does and moving that much weight is going to harm them.”

Of course, with the advent of the winter season, slippery parking lots are the norm, and reminding folks of the hazards is important.

“We have tried to educate employees on things like not loading your arms with stuff or wearing appropri-ate shoes for the conditions, but it does not seem to sink in,” he says.

• Equipment disinfection. The proper repro-cessing of diagnostic equipment such as endoscopes continues to be a major problem in clinics and hospi-tals, with some studies estimating that up to 30% of scopes still contain biohazardous dirt and matter that could transmit infections. In addition, some experts say even routine tasks such as disinfecting countertops from pathogens such as HIV, hepatitis, and tuberculo-sis is something that clinics and hospitals are getting wrong on a routine basis.

“I am shocked at the things I see in doctors’ of-fices,” says Rooker, who specializes in performing mock healthcare inspections. “They tell me the cleaning people take care of that with cheap products that they might use to clean a bank or hardware store. I went so far as calling the cleaning people, and they hung up on me. It has to be hospital-grade germicidal solution.” H

out before fire crews arrived, but it still caused about $30,000 of damage.

Reports indicated that an autopsy determined that Turner’s death was accidental, and resulted from smoke inhalation as well as severe burns that caused complications to the hypertensive cardiovascular dis-ease for which he was being treated.

“This has been very traumatic for our staff,” hos-pital spokesperson Mary Lynn Carver told The Sun. “They moved very quickly as soon as they smelled smoke. It’s obviously traumatic to lose a patient, and they had to evacuate other patients from other rooms.”

By nature, hospitals are places where people come to recover, and their population can be very difficult to move, so any death in a patient room due to fire can be traumatic for patients. Reports indicate that Turner had not been on oxygen therapy, which could have made the fire much worse since fire can spread rapidly in an oxygen-rich environment.

Patient deaths resulting from hospital fires are relatively rare occurrences, but as recent events have shown, they still happen.

A November 8, 2013, fire in an 11th-floor patient room at the University of Maryland Medical Center in Baltimore caused the death of a man suspected of smoking.

William Turner, 53, was killed in the fire that ap-parently started in his hospital bed. Hospital officials declined to comment on the fire, pending a hospital investigation; fire department investigators have said in published reports that a cigarette butt and dispos-able lighter were found on the floor in the room and a pack of Kool cigarettes and a lighter were found in a bag in a wheelchair by Turner’s bed.

Investigators told the Baltimore Sun that the fire apparently started in the bed, and also burned enve-lopes and magazines in the bedroom before burning the bedding and Turner’s lower extremities.

Hospital staff members were able to put the fire

calls for improved response protocols after Baltimore hospital fire death Smoking is suspected in patient room blaze



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sure people are putting that risk at the forefront. In the presence of static or a cigarette, you could have a bad outcome.”

In fact, hand sanitizer—today considered one of the most important tools in the infection control battle—is to blame for a fluke fire last February at Doernbecher Children’s Hospital in Portland, Ore., that left 12-year-old Ireland Lane with third-degree burns over a fifth of her body.

In the bizarre incident, Lane—in the hospital for kidney cancer treatment—apparently had used hand sanitizer to clean a table and olive oil to remove glue residue from leads stuck to her head. Attempt-ing to prank her father who was dozing next to her, she rubbed the plastic mattress she was lying on and meant to give him a playful shock. Instead, the vapors from the sanitizer caught fire and were fed by the oil in her hair and on her shirt. She has since begun recovering from her burns, but has been forced to go through several surgeries and skin grafts.

Clearly, it was a fluke accident, and facilities have since reassessed their use of olive oil and safety protocols with sanitizer. Just as in the case with the Baltimore fire, there is only so much the staff could have done to prevent the blaze. Hand sanitizer is an important substance present in hospitals that isn’t go-ing anywhere anytime soon. In the event of Baltimore, safety experts say despite rules prohibiting smoking, a patient who is determined to have a cigarette is going to find a way.

“We cannot stop those who are” intent on smok-ing, says Tom Salamone, president of Code Enforcement Corporation in Yonkers, N.Y., and a hospital safety expert for 30 years. “It’s not only easy for them to have a cigarette, but easier for the fam-ily to sneak it in. A lot of people look at us like we’re crazy when we try to explain that it’s against the Life Safety Code®.”

Procedures in place to protect lifeHospitals in the U.S. today are built with fire protec-

tion in mind, which contributes to the relatively low incidences of fires and fire deaths in this country. If a fire breaks out, often it is very difficult to evacuate patients. That’s why the buildings are designed with a “shelter-in-place” mentality. Patient rooms and cor-

“In the past, we would have multiple deaths from smoke inhalation in a hospital fire,” says Peggy Prinz Luebbert, MS, MT(ASCP), CIC, CHSP, creator of IP-Bootcamp in Omaha, Neb. She’s also president and founder of Healthcare Interventions. “Because of new standards, that doesn’t happen any-more, or at least it shouldn’t.”

Hospitals designed with fire in mindDisastrous hospital fires in the United States are

a rare phenomenon, and are attributed to strict fire codes and regulatory agencies that monitor standards in place to protect patients.

Take as contrast a 2011 fire in Kolkata, India, that killed 94 people at the Advanced Medical Research In-stitute Hospital. Considered a state-of-the-art facility, the 180-bed hospital went up in flames when a small fire in the basement burned out of control.

Reports indicated the hospital offered deluxe luxury suites, a top-notch surgical suite and cancer center, and state-of-the-art emergency room. This may have been the case, but the air-conditioned, hermetically sealed environment allowed for the fire to burn out of control.

The hospital apparently had no evacuation plan, and staff members took a long time to call the fire department.

Even then, they told responding crews that it was only a small kitchen fire. After the fire was put out some 12 hours later, it was learned that doctors on duty had fled—leading to homicide convictions and allegations that the hospital’s fire suppression systems weren’t working.

Thankfully, fires like the one in India are an anom-aly, but experts say it bears bringing the discussion of fire safety back to the forefront because the dangers lurk in the hospital environment every day.

“There’s this conscious acceptance that we accept hand sanitizer as a very good thing, but we forget that it is a very hazardous, flammable chemical,” says Marge McFarlane, PhD, CHSP, CHFM, HEM, MEP, CHEP, principal of Superior Performance, LLC, in Eau Claire, Wis., who adds that sometimes the “competing priorities” of infection control and life safety can get in the way of each other. “We have put flammable liquids back into healthcare, and I am not



February 2014

ridors are built with fire-resistant doors meant to be shut in the event of a fire, creating “compartments” that can protect those inside for hours at a time until help can arrive and put out the fire.

In addition, The Joint Commission and other regulatory agencies have certain standards in place that make compliance mandatory in order to maintain accreditation status.

Still, human error can make these protections useless against a fire, making vigilance a constant necessity.

“I am surprised by the number of hospitals that have solved their corridor clutter problem by putting stuff in the patient rooms,” says McFarlane. “They set up a life safety finding right there.”

McFarlane says that even The Joint Commission has stopped enforcing no-smoking policies, and it really is up to the hospital to let visitors know smok-ing cannot be part of the environment.

“It’s not in their focus anymore,” she says. “The challenge for every security officer in the universe is how to [politely] challenge the family member of someone who has been brought in and tell them to go across the street to smoke.”

In the meantime, the best defense that hospital staff have against fires in patient rooms is vigilance and training. Even though smoking has been banned from most hospitals for about 15 years, experts say those patients who are determined will try to smoke anyway. The idea, they say, is to confront those known to have a smoking history and to offer alter-natives, such as a patch or even electronic smokeless cigarettes.

“You can tell if someone’s been smoking,” says McFarlane. “It’s on their clothes and it’s on their health history. I think it’s easy to not confront them about smoking. We used to have wastebasket fires all the time.”

A fire in a patient room can be a traumatic event for those tasked with helping patients get better. Sal-amone says he recalls a fire at a hospital in New York City where three patients died.

In that event, it became clear that the fire was out of control and could not be quickly put out. A nurse made the decision that the patients could not be saved, and to save other patients on the floor, the door was closed to contain the fire according to training procedures.

“She’s never been the same,” Salamone says. “She had to make the toughest decision that was against her ethics. You are taught to save all lives, and the minute I shut that door I’m telling the patient you are a goner.”

To avoid these kinds of situations, Salamone says the hospitals he has worked in continually hold fire drills that teach staff to quickly and thoroughly search rooms in the event of a fire, and then mark them properly so time isn’t wasted on re-searching later.

“Some of these people are taught that if you don’t see a patient on the bed, it’s clear,” he says, adding that people act in unpredictable ways during a fire. “People panic and hide. They hide out of fear, usually because they are the ones who started the fire. That’s why I want staff to check the bathrooms, in closets, and under the beds.” H

Q&A: Preparing for power outages in a hospitalEditor’s note: Considered a rare event in hospitals

that are well prepared with a backup plan, power outages can still threaten to disrupt the continuity in a place that thrives on its ability to survive dur-ing the worst of disasters. Safety consultant Steve MacArthur discusses the threat of power outages and what safety officers should be doing to assess and prepare their facility.

Q How often do power outages occur in hospitals,

and what are some of the main causes?

MacArthur: This varies from location to location. The Joint Commission issued a Sentinel Event Alert (#37) a few years ago that recommended hospitals conduct an evaluation of the reliability of their normal power supply in order to identify appropriate redun-dancies for their emergency power needs. I guess in



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terms of causes, I suspect that weather-related out-ages would be at the top of the list, with mishaps (car hits utility pole; squirrel fries transformer) as a well-distant second. And some of the mishap types—prob-ably not the squirrels—could be weather-related due to slippery conditions, etc.

Q A power outage just struck my hospital. What are some of the first things I should do, and what

are my priorities?MacArthur: The priority is to make sure that the

emergency generator(s) came on; then you would work to verify that everything that is tied into emer-gency power is up and running. The Sentinel Event Alert also recommended an evaluation of what ser-vices, etc., are supported by the emergency power system and to let folks in the organization know what’s on emergency power and what is not. That way there can be some planning as to which services might be disrupted as the result of the outage. Next up is trying to figure out how long the outage is likely to last—in many, if not most, instances, this requires communication with the utility company. One of the ongoing important tasks is to make sure you can reach someone at the utility company and have some sort of direct number.

Q A hospital without power is essentially worth-less. What should a hospital safety official be

thinking about when assessing his facility for a poten-tial power failure?

MacArthur: Once you have a sense of the likely duration of the outage, then you need to look at how much fuel there is on hand and whether you need to be thinking about how you will obtain more fuel if the outage is likely to be more than, say, a few hours. There is no hard-and-fast rule for this. Every event is different; every hospital is different as a function of what services are supported by the emergency power system. There can be some variability based on what time of day it is, which day it is, etc. In all likelihood, an outage of any more than a momentary duration would “drive” the establishment of the hospital’s inci-dent command structure. There are lots of decisions to be made relative to the potential curtailment or even discontinuation of services and then the need to

communicate those decisions to the rest of the orga-nization in a timely fashion. Some of this stuff can be game-planned in advance, but there are always going to be little wrinkles that fall under the unanticipated category. The only truly consistent aspect of these types of events is their inconsistency. Getting through these events frequently means making good decisions from moment to moment.

Q What are some redundancies and backups that can be employed to help in the event of a

blackout?MacArthur: Well, all hospitals are more or less

required to have some emergency power capacity, and the overarching requirement for hospital leadership is to have emergency power capacity that is adequate/appropriate to the care and services being delivered. But there is a process that needs to be in place to keep whatever you have in good running order. It would be most unfortunate to run out of fuel or to have some-thing break down because it has not been properly maintained. If a facility professional is going to baby any equipment, it’s going to be the emergency genera-tors, and they’re going to have a means of acquiring a backup generator in case there is a problem with their main generator. Some folks have the luxury of hav-ing on-site redundancy, but that can be a very, very expensive proposition—way more than most folks can afford. But one of the other truisms is that you better have a solid backup source, because if it’s a regional event, you may be in competition with other hospitals for those generators and a lot of time it’s the person who shows up first with the closest thing to cash that gets the equipment.

Q In a power outage, should I be evacuating my patients or sheltering in place? What if I can’t

provide services?MacArthur: In most instances, as long as your

generators are working properly, you should be able to maintain care and services (to the extent that you can support same on emergency power), so evacuation of patients shouldn’t be necessary. Again, going back to the responsibility of organizational leadership, there is an expectation/mandate that hospitals will be ap-propriately equipped/maintained, etc., in accordance



February 2014

Safety experts say the message being delivered is the same: It’s a growing problem and something needs to change, but don’t expect anything different anytime soon.

A new round of recent shootings in several hospitals and a knife attack in a Texas medical clinic has again renewed the debate about violence in the healthcare arena and what should be done about it.

More violence rattles hospital staffShootings and a fatal knife attack renew debate over security, underline need for more training

with the care and services provided, so you really can’t be getting into situations in which you have to “dump” your building if there is a power outage. Consideration of evacuation should really be in response to a cata-strophic event. That said, if you lose normal power and then your emergency power system goes kaput, then you are really looking at tough decisions, which also goes back to the incident command structure. Losing normal power definitely places a hospital in an elevated state of vulnerability, but that elevated state should be manageable within the framework of a “normal” emergency. A truly catastrophic event such as a direct hit from a tornado or earthquake? All bets are off at that point and it’s about hanging on for dear life.

Q In a communitywide outage, how can my hos-pital, assuming we have backup power, be a

helpful resource?MacArthur: Depending on the circumstances,

hospitals could provide shelter, etc., but that would (or should) be a role that is very clearly defined with-in the context of the community’s response plans. None of this stuff can really wait until it is needed to establish response expectations. I recall an instance “back in the day” where communities felt that they could bring as many “victims” to the hospital as they had, even if that number were in the thousands. It took a lot of education to get them to understand that emergencies were something that had to be managed, not merely responded to. It’s much better now, but it wasn’t so long ago that the interactions between hospitals and communities, and through that the level of preparedness, were very much less

than they are now. The Boston Marathon bombing is a good example of how well a coordinated response can work—it sucks that it took an event like that to demonstrate the effectiveness of the planning and preparedness activities, but the process worked as designed with minimal chaos (beyond the chaos gen-erated in the moment).

Q What are some ways that a hospital can ensure that it is a priority when it comes to getting back

online after a power outage?MacArthur: In this day and age, hospitals are

certainly considered part of the critical infrastruc-ture, but it never hurts to verify your status in the community hierarchy with the utility company. And, if you get the sense that your status is not at the top of the food chain, then it goes back to leadership to work to make sure that it is. I would like to think that a simple conversation with the utility company would be more than enough; hospitals are, after all, among the largest users of utility systems and it only makes good sense to keep your biggest customers happy. But if that doesn’t work, you can enlist the support/voice of the state hospital association, municipal government, etc. This stuff is way too important to leave to chance and nobody wants to be on the front page of the local paper because they had not done all that they could, including advocacy, to be prepared to handle an emergency. Ultimately, it is about just that, even from a regulatory perspective. How do you know your hospital is adequately/appropriately prepared to respond to an emergency? This can’t be guesswork; it has to become fairly certain knowledge. H



February 2014

11

“There’s no way of keeping guns out of hospitals un-less you pat everyone down or have metal detectors,” says Peggy Prinz Luebbert, MS, MT(ASCP), CIC, CHSP, creator of IP-Bootcamp in Omaha, Neb., and president and founder of Healthcare Interven-tions. “Hospitals aren’t going to do that. We aren’t there yet.”

Milwaukee police were able to avert a major tragedy November 14, 2013, at Children’s Hospital of Wiscon-sin after 22-year-old Ashanti Hendricks walked into the neonatal ward of the hospital with a gun.

Hendricks was approached by two Milwaukee police officers in the hospital after a woman called to tell them he was armed and that he had outstanding war-rants for his arrest on felony handgun charges.

At first Hendricks appeared to cooperate with po-lice, according to reports, but he then tried to escape and pulled a gun. After a scuffle with the officers, he was shot in the arm and arrested without further incident, but it sent the hospital into immediate lockdown.

Hendricks was charged with two counts of jumping bail and possessing a gun as a felon as well as resisting or obstructing an officer.

“Now that we’ve allowed concealed carrying, this has become a security nightmare,” says Marge McFarlane, PhD, CHSP, CHFM, HEM, MEP, CHEP, principal of Superior Performance, LLC, in Eau Claire, Wis. “These people won’t be stopped by a nice sign on the door.”

Although that incident ended relatively peacefully despite a huge police response, others had more tragic endings.

In Springfield, Mo., a man was killed and his wife severely wounded December 2 in a shooting in a hos-pital room at CoxHealth Hospital.

The shooting occurred while 69-year-old Carolyn Cox was visiting her 79-year-old husband, Booker Cox Jr., in his ninth-floor hospital room. Cox was pronounced dead about an hour after the shooting, but officials did not release the condition of his wife. Later investigation found that Cox had apparently shot himself, but no details about his wife’s shoot-ing were available as of presstime as it is still under investigation.

On November 26, a man proved a gun is not needed

to commit violence when he walked into a surgical clinic in Longview, Texas, with a hunting knife and went on a stabbing spree.

According to news reports, Kyron Templeton, 22, apparently walked into Good Shepherd Ambulatory Surgical Center at around 7 a.m. yelling “You’re not going to kill my mother!” before he began randomly stabbing people in the clinic.

A nurse at the clinic, Gail Sandidge, rushed in to help some of the victims and was killed when Temple-ton stabbed her in the chest. Witnesses said she died attempting to save lives. Four others were injured in the attack, according to news reports.

“Nurses are protectors by nature. And Gail, she fit that profile,” Steve Altmiller, CEO of Good Shepherd Health Systems, said in a published report. “She was protecting her patients in an act of courage today, and in so doing, she lost her life.”

Same old storyViolence in hospitals is something no one wants to

expect, as it is supposed to be a place where people come to heal. Unfortunately, violence continues to escalate and become almost a part of life in some hos-pitals for staff members.

“It depends on the environment you are in,” says JoAnn Lazarus, president of the Emergency Nurses Association, based in Des Plaines, Ill. “I’ve been in places that never think about security and others that are deciding how to put metal detectors into the facility. It doesn’t matter if you are in rural Kansas or Detroit, anyone can have something happen. We always have to understand our environment.”

Safety experts say that violence in hospitals is some-thing that is born from a place where emotions and stress run high.

It’s not hard to imagine that an old man scared of losing his lifelong partner might turn suicidal, or a son angry over a botched surgery might turn to violence to deal with his emotions.

“It’s a high-stress environment,” says Chris Hengstebeck, system director of security for the Beaumont Health System in Royal Oak, Mich., and for several hospitals in the Detroit area. “I tell my staff to think of when you are at your worst. It’s when you have a loved one in the hospital. You are in a height-



February 2014

staff training in many hospitals across the country, and some have even pulled surprise drills on staff with patients still in their beds.

A few have also done live drills with police firing blanks to simulate an active shooter and used real volunteers as “victims.”

“When the police come in and start shooting, it’s really scary because it was so real,” says Steven Shay, safety coordinator for Winchester (Mass.) Hospital. Shay was involved in a live-action drill two years ago at Cambridge Hospital outside of Boston. “It requires a significant amount of planning because you have to think about patients, staff, and the surround-ing community.”

In a real active shooter situation, so much chaos is inherent that in some hospitals staff are being trained to turn the situation into just the opposite.

In Green Bay, Wis., staff at St. Vincent, St. Nicho-las, and St. Mary’s Hospitals participate in drills that encourage them to hide, stay quiet, and empty out the hallways.

“Everybody into their rooms. Doors are locked. Lights are out. Essentially this place does become an absolute ghost town,” said Steve Pelch, safety divi-sional director for the three hospitals, in a published report.

Some hospitals, including the staff of Children’s Hospital of Wisconsin, train with local police de-partments in a tactic known as “Run, Hide, Fight.” Basically, a staff member’s last resort should be to fight back during an active shooter scenario. Staff are taught to run away first and hide. If they need to fight back, they can use IV poles, oxygen tanks, computer monitors, and even large binders as a weapon to help protect their patients and themselves.

“Some people would immediately try to go tackle the guy,” Shay says. “I’ll give you brownie points and a Band-Aid, but I’d rather you not need the Band-Aid.” H

ened state.”That mentality is something that stretches to hos-

pitals in the most rural parts of America as well as the cities.

According to Luebbert, a shooting in the psychiatric unit of a rural hospital in Nebraska where she works was the catalyst to get a state law passed making it a felony to interfere with healthcare workers doing their job.

“Most facilities have a policy of not touching the gun, control the activity around the gun, and then call 911 or security. You don’t want to escalate issues that you are not trained to handle. That person brought a gun in for a reason.”

“Now that we’ve allowed concealed carrying, this has become

a security nightmare,” —Marge McFarlane, PhD, CHSP, CHFM, HEM, MEP, CHEP

Luebbert’s point brings up an argument that hos-pital safety officials continue to grapple with: Should hospitals beef up their security to the point where weapons are introduced or police officers make a con-stant presence?

Most safety officials say no, the hospital is not a place where the threat of violence should be met with a mili-taristic show of force. For the most part, they agree that hospitals should remain a nonthreatening environment where patients can come to heal. Most hospital security plans revolve around the use of nonviolent tactics such as verbal de-escalation when a patient threatens to become violent.

“People in law enforcement don’t make good hospi-tal workers,” says Hengstebeck. “They’ve been jaded by the street, out dealing with the criminal element. We need to be skilled in our diffusion techniques. A simple response can trigger escalated behavior or de-escalate.”

Training for the real thingDespite this sentiment, many hospitals are sharpen-

ing up their responses to violent situations by practic-ing for the real thing with local police departments. Active shooter drills have become a normal part of

Contact Managing Editor John Palmer at [email protected] or 781-639-1872, Ext. 3265.

Questions? comments? Ideas?

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February 2014Volume 22 Issue No. 2

Healthcare Security Alert

Supplement to Briefings on hospital Safety

Exploring early lessons learned from San Francisco General HospitalAfter patient was found dead 17 days after going missing, hospitals should review their security protocols

San Francisco (UCSF) who works at SFGH, later con-tacted authorities to provide additional information.

During a press conference on November 6, San Fran-cisco Sheriff Ross Mirkarimi apologized for the depart-ment’s slow response and incomplete search. Mirkari-mi said that officers started the search nine days after Spalding Ford went missing and only checked half of the facility’s stairwells. After the UCSF researcher reported seeing a body in the stairwell, Mirkarimi said a dispatcher told hospital officials that the secu-rity department would respond, but no one ever did. Mirkarimi disclosed other preliminary findings includ-ing the fact that authorities thought Spalding Ford was black or Asian when she was actually white, and that surveillance video from the time of her disappearance was unavailable because of faulty hardware.

According to a statement released by the San Fran-cisco Sheriff’s Department on October 28, the full investigation is ongoing.

“We are presently conducting an investigation ex-amining every aspect of this case,” the statement read. “This investigation has been continuous and encom-passes the following: Conducting interviews with em-ployees from different agencies and spanning different shifts to include San Francisco Sheriff’s Department employees as well as employees from the Department of Public Health; an assessment of policy and proce-

It was a nightmarish situation that emerged on Octo-ber 8, 2013, at San Francisco General Hospital (SFGH) and then quickly spiraled into a public relations catas-trophe as the story made national headlines. Two days after being admitted to SFGH, Lynn Spalding Ford, age 57, went missing. Seventeen days later, she was found dead in the stairwell of the hospital.

On September 19, Spalding Ford was admitted to SFGH for an infection. Two days later she disappeared. Family members have said that Spalding Ford was frail and may have been confused due to the medication she was taking. On October 8, a hospital employee found Spalding Ford in a stairwell during a routine inspec-tion. According to the San Francisco Sheriff’s Depart-ment, which was in charge of security for the hospital, the door to the stairwell was locked from the outside and was equipped with an alarm.

According to David Perry, a spokesperson for the Spalding Ford family, SFGH Chief of Staff Jeff Critch-field, MD, told the family that on October 4, a man was heard knocking on the door of the stairwell on the eighth floor, according to an article in the San Francisco Examiner. The man, who was wearing a hospital badge, according to the article, then told the female senior staff member who opened the door that there was some-one lying on the stairwell between the third and fourth floors. That man, a researcher at University of California

1



February 2014

the hospital’s safety and security systems, according to the Examiner. However, the publicity that this case has generated nationwide has also turned quite a few heads in the hospital security profession, and many other hospitals are closely following the case to see what will be determined through the investigation and what lessons they might learn.

“A lot of places are going to be looking at this and saying, ‘This cannot happen here,’ ” says John M. White, CPP, CHPA, president and CEO of Protection Management, LLC, in Canton, Ohio. “They are going to be looking to make sure that they have the processes in place to make sure it doesn’t happen; that’s just the way our country reacts. We react to tragedies, and often it’s at someone else’s expense, but you learn from their mistakes.”

It’s still early and many of the facts are still unknown, but based on what has been released and reported in the news, hospitals might consider looking at their own security protocols surrounding security rounds, tech-nology, and managing stairwells.

a facilitywide approachMuch of the blame for this particular case is being

directed at security for failing to properly follow up on a missing patient report and for failing to check all stairwells in the hospital. Generally, however, break-downs can occur at many different levels, says Bill H. Nesbitt, CPP, president of Security Management Services International, Inc., in Newbury Park, Calif., noting that not enough facts are known to truly make an accurate judgment on exactly what went wrong at SFGH. Nesbitt says he often recommends the hospital risk management department work hand in hand with the security department in an effort to better respond to cases involving missing patients.

“There have been cases where people have walked out of emergency rooms and lost their life,” he says. “Especially if it’s a contracted security service there is a tendency to blame the security, but what about the people whose care that person was in? There needs to be some coordination there.”

Based on the facts laid out in news reports, it certain-ly appears that security shoulders much of the blame as it relates to inadequate patrols and response to the reports of a body in the stairwell on October 4. But

editorial adviSory Board

Russ Colling, MS, CHPA, CPPHealthcare Security ConsultantColling and Kramer Salida, Colo.

Steven C. Dettman, BS, CHPADirector, Security and Visitor Support Services Mayo Clinic Hospital Phoenix, Ariz.

Linda Glasson, CHPA Security Consultant Suffolk, Va.

Steven MacArthurSafety ConsultantThe Greeley Company Danvers, Mass.

Anthony N. Potter, CHE, CHPA-F, CPP, FAAFSMarket Director of Public SafetyNovant Health Winston-Salem, N.C.

Fredrick G. Roll, MA, CHPA-F, CPP President and Principal ConsultantHealthcare Security Consultants, Inc., and Roll Enterprises, Inc. Frederick, Colo.

Senior Director, ProductErin [email protected]

Senior Managing EditorJay [email protected]

This document contains privileged, copyrighted information. If you have not pur-chased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission.

dures related to hospital security; an assessment of the operability of alarms and fire life safety systems; and a review of communication procedures. In conjunction with DPH administrators and staff from San Francisco General Hospital, we are continuing to review all secu-rity protocols.”

In the fallout from the incident, Mark Nicco, an attorney for the sheriff’s department, told the San Francisco Chronicle that a sheriff’s sergeant, two senior deputies, and a civilian sheriff’s dispatcher had been re-assigned. Additionally, three deputies have been added to the hospital security force with more on the way.

The Chronicle also reported that SFGH officials tried to replace sheriff’s deputies and institutional police officers with a privatized security unit for the past three years but were routinely stymied by the Service Em-ployees International Union. Records also show the sheriff’s department was stretched thin, with a quarter of deputies on duty at the hospital collecting overtime at any given time.

In addition to the internal investigation by the sher-iff’s department, SFGH has also reached out to UCSF Medical Center to perform an independent review of


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February 2014

“A single officer patrolling the staircases would have found the patient earlier,” Vellani says. “It’s unknown though when the patient expired, so patrols may not have saved her life.”

A security risk assessment of all physical and op-erational security practices is the best way to identify potential gaps in security rounds and adjust officer training as needed, Vellani says. Additionally, the use of technology—particularly patrol audit systems or elec-tronic guard tour patrol systems—is imperative to help ensure officers are patrolling all areas of the hospital.

“If you don’t have some kind of verification that people are walking into the stairwells, you’re only as-suming that officers are doing it,” White says.

Electronic guard tour patrol systems are utilized in a variety of industries. Common manufacturers include The Pipe®, Deggy®, and Detex, which operate using radio frequency identification devices (RFID) or bar codes and a portable electronic sensor that is usually the size of a flashlight. During his or her rounds, the officer uses the sensor to electronically check in at bar codes or buttons that are strategically placed through-out the facility. This information is stored in a database so security directors can verify when and where the officer conducted rounds.

“Usually what I recommend is officers do a tour in the first hour, sometime in the middle, and within an hour of when they get off,” White says. “So you’re not telling them exactly when to do it, but you’re giving them a range.”

The cost of these systems depends on the size of the facility, but they offer the benefit of being a onetime cost, rather than the reoccurring cost of hiring addi-tional officers.

“When it comes to accountability, it’s priceless be-cause it gives you total accountability for what security is doing,” White says. “A lot of times hospitals will put [RFID sensors] all the way at the back of mechanical rooms so officers need to walk through the entire thing, which means they can see any water leaks and fire haz-ards, or notice any discrepancies or problems before it becomes a larger issue.”

Alternatively, hospitals can utilize video cameras to supplement officer rounding, Nesbitt says. Newer surveillance technology has produced “smart” cameras that can be trained to recognize abnormalities, like a

security is not solely to blame for the patient’s death, says Karim H. Vellani, CPP, CSC, an independent security consultant for Threat Analysis Group head-quartered in Houston. “A comprehensive security risk assessment would have identified the lack of staircase patrols and a recommendation would have resulted, but there is no guarantee that leadership would have implemented the recommendations,” he says. “If leadership is receptive to the security risk assessment findings and works to implement recommendations in a timely manner, patrols would have been occurring in the stairwells and other areas.”

Vellani says it’s interesting to note that some orga-nizations—hospitals and others—buy into compliance issues (e.g., compliance with The Joint Commission, HIPAA, etc.) identified in a security risk assessment but are slower to respond to other issues that may cause security to be less than optimal.

Nesbitt adds that one of the best things hospitals can do is increase overall security awareness in their facil-ity, especially among non-security staff, which he likens to a neighborhood watch program. All employees need to understand how to identify suspicious activity and how to respond to it. Frequently, frontline staff know that they need to watch for suspicious activity, but they can’t always define what that is or what a suspicious person looks like, Nesbitt says.

Employees also need to receive at least some basic training on how to handle potentially violent situations and be able to serve as a reliable witness if a crime oc-curs. “It’s the same way they train bank tellers if they get robbed,” Nesbitt says. “You can ask an untrained teller what the robber looked like and he or she will say, ‘He had a big gun in my face,’ just because that’s what they focus on—as well probably anyone would. But it doesn’t take long for someone with a little bit of train-ing to take an inventory of their height, weight, what shoes they are wearing, etc.”

Supplementing security rounds with technologyWhat is baffling to many who have followed the cov-

erage of the Spalding Ford case is how a security patrol did not find her over the course of 17 days. For other healthcare facilities, this highlights the need to train security officers to patrol all areas of the hospital—par-ticularly stairwells—at least once per shift.



February 2014

“Staircases are sometimes neglected during security patrols,” Vellani says. “Walking staircases sometimes provides evidence of transients sleeping in the staircas-es or evidence of theft [e.g., discarded scrubs, medica-tion packaging]. To increase patrols in key areas [e.g., closed patient units, construction areas, storage areas, staircases], some hospitals have used patrol audit sys-tems [or “guard tour systems”] to increase accountabil-ity that security officers are patrolling staircases and other low-traffic areas on a consistent basis.”

Possible regulatory fallout The same ongoing story in San Francisco that has

caught the eye of many in the security industry may have also caught the eye of regulators and surveyors, White says. Joint Commission surveyors will often use recent events or news items as part of their survey.

For example, White says he has seen surveyors ask about lockdown procedures related to natural disasters following Hurricane Katrina or even the tsunami that hit Japan in 2011. In this case, surveyors may be directing more questions to security directors about how they do rounds, whether they incorporate stairwells into those rounds, and how they respond to a missing patient.

“It wouldn’t surprise me if they are probably already using this as an example when they talk to security people and saying, ‘When a patient goes missing, what do you do and how does your process work?’ ” he says. “I’ve been preaching about this for years about stair-wells, so to me when I saw this, it was a classic example of why I tell people that stairwells present a lot of risks that you must account for.”

White says you need to have some process in place to reduce that risk to the minimum level you can get it. “You can’t be there 24 hours a day, but I would think you can go through each stairwell at least once in an eight-hour shift.”

Hospitals around the country are also going to be paying attention to the legal fallout of this case, which could be significant if a court rules the hospital was liable for this patient’s death. At the very least it will probably drive more hospitals to take a closer look at their risk assessment, just as other national tragedies—the Newtown school shooting or the Boston Marathon bombing—have forced hospitals to reevaluate emer-gency preparedness procedures. H

bag that is left behind or a person who comes into view.“Video has gotten much smarter,” he says. “You can

teach the camera to respond to certain events like move-ment. Every time there is movement, that camera view will come popping to the top of the screen and maybe there is warning. Someone looks at it and sees every-thing is fine, or if you recognize something that doesn’t look right, that might be a reason to check it out.”

However, White argues that cameras are insufficient to monitor stairwells, expensive to install, and are often used to review an incident after the fact rather than in real time. If you do have cameras, they need to be in-spected routinely, Vellani adds. At SFGH, for example, camera footage was lost due to hardware errors.

“This seems to indicate that hardware was not in-spected on a routine basis,” Vellani says. “Dedicated security operators typically inspect images at the begin-ning of each shift. If no one is dedicated to monitoring images constantly [or even irregularly], or if a vendor is not contracted to regularly test equipment, it’s likely that hardware failures are only identified post-incident.”

The danger of stairwellsWhite says he routinely warns organizations about

the inherent dangers of stairwells, which are often rarely used and therefore ignored by staff and security officers. However, these areas present a very high risk.

For example, stairwells on the ground floor create a hiding space underneath the stairs that should be monitored during officer rounds. Stairwells also carry the risk of trips or falls—either by an employee, a patient, or a visitor. White has also been in buildings that have fire doors or roof access doors that are supposed to be locked, but aren’t because they aren’t routinely checked.

“There have been places where sexual assaults have occurred in stairwells, there are many slips and falls in stairwells, or purse snatchings,” he says. “It’s one of these things where people usually ride the elevators and most people avoid the stairwells, and so they can be neglected.”

By using an electronic guard tour patrol system, hos-pitals can place sensors inside the stairwell so that of-ficers must walk into the stairwell during their rounds. Hospitals should also instruct officers to use the stairs rather than the elevator during their rounds so that they are covering every part of each floor.

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