Play it Safe

Take a look at the brochure for your next professional society meeting and you'll likely find a session about patient safety on the agenda. Preventing medical errors, communication systems to improve patient compliance, maintaining problem and medication lists, and patient education are all hot topics.

As these issues grab headlines, however, don't overlook some of the more basic aspects of office safety. Providing a physically safe practice setting is an important component of quality care and is good business, too; many of the measures you put in place to protect patients also safeguard your staff and reduce the risk for accidents and lawsuits. 

Many medical offices are safer today thanks to two prominent government mandates. "OSHA was the big bogeyman 10 years ago, but now people are in compliance and as a result, patients are safer," says Bruce Bagley, MD, medical director of quality improvement at the American Academy of Family Physicians.

The other directive that ultimately improved safety is the Americans with Disabilities Act (ADA). "The requirements for ramps, safety bars in bathrooms, and that sort of thing have all made the offices safer for everyone," adds Bagley.

Know your practice's needs

What makes your office a "safe office" varies by specialty, the scope of services you offer, the size of the practice, and even geographic location. What constitutes risk in a two-physician, small-town surgical group is quite different than in a large, inner-city primary-care clinic. In terms of your location, you'll need special procedures in place if you have icy sidewalks in the winter or if your office is in a tornado-prone area. Lab and radiology services add complexity to the safety equation. 

G. Steve Rebagliati, MD, MBA, director of medical affairs and quality management at the Oregon Health Sciences University in Portland, says times have changed when it comes to medical-office safety. "The trend in the past has been to look backward. This was called critical event review. The new trend is to look ahead, to anticipate what can go wrong, and plan for that. You should think about the major categories of emergencies you could have depending on where you are," he says. 

The supplies and equipment you keep on hand for emergencies will depend on your patient population and how close you are to a hospital with an ER. If you have a crash cart it should be stocked in proportion to the size of your practice. Put someone in charge of checking it monthly to make sure everything is in working order and in the proper place and that drugs are not outdated. (For an example of crash cart supplies and set-up, go to www.ucdmc.ucdavis.edu/cne/Resources/ClinSkil/Crashcrt/topdrawer.htm.)
Automatic external defibrillators (AEDs), now commonplace in airports, shopping centers, and other public areas, can also be practical for medical offices, especially in rural or congested areas where getting an ambulance to the office could cost valuable minutes. The machines are simple enough that almost anyone can use them and they are reasonably priced at around $1,500. Remember, however, that purchasing an AED is not a substitute for having staff trained in CPR.

Policies in place

Kathleen LePar, RN, MBA, senior consultant with Beacon Partners in Weymouth, Mass., is an advocate of concrete policies, procedures, and systems-based safety plans. "Training staff on your policies is so important," says LePar. "If you make a policy and put it in a book on a shelf, you won't get the outcome you want."

A good safety manual accomplishes several things. First, it forces physicians and staff to think about safety and the issues that are unique to the practice. Second, it's an excellent training tool for new staff and for refresher courses for everyone. Third, it can help you stay in compliance with OSHA, CLIA, ADA, HIPAA, and local building codes.

The Medical Group Management Association (MGMA) publishes "Operating Policies and Procedures Manual for Medical Practices" by Bette Warn and Elizabeth Woodcock. It includes sample policies on exposure control, sharps disposal, fire control, developing a safety committee, and more.

Buying a manual like this is an excellent place to start, but the best option is creating a handbook unique to your practice. A three-ring binder with sections on bloodborne pathogen exposure, infectious disease, hazardous waste disposal, emergency procedures, hazardous substances, building exit plans, and reporting unsafe situations -- to name a few -- can be easily updated and used for training new staff.  

Speaking of training

Too many practices make the mistake of assuming an experienced medical office employee knows how to recognize, prevent, and deal with safety hazards or emergencies. Just as bad is presuming that when staff has been trained once that's the end of the story.

"The best-run groups set aside regular staff training hours," says Rebagliati. "They'll create a training roster and over the course of a year cover subjects that will give them the biggest return on the investment of time, depending on the patient population.

Developing something like this just takes a few hours of thinking, and then creating a plan that fits your budget and that you'll follow through on." 

Sandra Adams, OSHA compliance manager for West Clinic, an oncology/hematology practice in Memphis, Tenn. has instituted a comprehensive online training program for staff. "It's on our intranet," she says. "I let managers know when training is due so that during a slow time staff can log on and do the program and answer the questions. Then they enter a code word to move on to the next training." Adams says her staff members are trained every year around their anniversary dates; many safety experts agree that annual training is a good idea.

If you don't have the technical capabilities to provide online training, there are plenty of low-tech ways to keep staff up to speed. Presentations at staff meetings, hands-on practice sessions, video training (www.safetytrainer.com, www.coastalhealth.com), and sending staff to seminars are all good options. 

Your local hospital most likely offers CPR courses for their staff. Inquire about sending members of your office staff to this training.

Depending on your patient population, you may want to have clinical and physician staff trained in advanced cardiac life support as well. Having employees certified in basic cardiac life support (BCLS) or advanced cardiac life support (ACLS) raises the confidence level among staff so that they are better prepared to handle an emergency should one arise. 

Good communication is another key factor in maintaining a safe office. "Staff should know how important it is to report something when it happens. Tell them it's not about blame or shame when someone makes a mistake," says LePar. "It's often a systems problem and it should be addressed. Let the staff know who to go to and that it's OK to make a report." 

Managing infectious diseases

When HIV/AIDS first made headlines in earnest, the push was on to protect staff and physicians from potentially infected blood products. "Universal precautions" was the name of the game and everyone jumped on board (much to the delight of latex glove manufacturers). It has been reported recently in the lay press that "AIDS fatigue" may be setting in -- younger people don't remember the initial scare and have become more casual in their behaviors. 

Likewise, be sure your practice doesn't suffer from "universal precaution fatigue." It's worth looking around, quizzing staff about procedures, and retraining everyone periodically on the importance of consistently using gloves, eye protection, and other personal protective gear, as well as avoiding needle sticks and the proper disposal of infectious waste.

In 2001, OSHA updated standards on needle-stick prevention to state that employers should involve staff in the selection of safer needle devices and keep a log of injuries caused by contaminated sharps. Comprehensive information is on OSHA's Web site (www.osha-slc.gov/SLTC/bloodbornepathogens/index.html) where you can also find documents that can be used for training or inclusion in your safety manual.

Sandra Adams says one way to drive home the point about wearing personal protective equipment is to use real-life illustrations. "Without revealing names, I give examples of people I know who have been exposed to let staff know it really can happen. Even though we think we know our patients well, we don't always know if they have a communicable disease," she says.

Have a plan in place in the event there is exposure to HIV, hepatitis, TB, staph, or other serious infectious diseases. "Think ahead of time about your patient population and what relative exposures you have. Keep a packet on hand with lab forms, consents, information about where an exposed individual goes for follow-up, and whether immediate prophylaxis is needed," says Rebagliati. 

More services, more concerns

Practices with in-office lab and X-ray facilities have special safety issues. If you are diligent about CLIA guidelines, that should cover you for safety as well as quality in your lab. Everyone -- not just lab techs --  should be aware of which chemicals are hazardous and what to do if there is a spill or exposure. Include this in your training and keep medical safety data sheets updated.

Well-trained radiology techs are safety conscious and keenly aware of the risks of radiation exposure. But what about other staff who may come into contact with radiation? The nurse who comes in to help position a patient, for example? Or the receptionist who breezes in and out to deliver messages? Anyone who goes into the imaging area should have a safety orientation and wear a radiation detection badge. Set a good example for staff by being safety-conscious yourself.

Danger from outside

Although the threat of bioterrorism may be remote, the possibility does exist. Appoint someone in your office to review CDC bulletins and stay in contact with your local health department. Periodically remind staff and physicians to be on alert for patients presenting with unusual symptoms that might indicate biological or chemical exposures. If you notice anything unusual, contact your county health department. 

Violence in the medical office, while rare, is something you should be aware of. Whether it's an unruly patient, the angry spouse of a staff member, or a random intruder, a threatening situation must be handled in a way that protects the safety of both staff and patients.

Never hesitate to dial 911 in an emergency. Staff should never try to physically subdue a violent person by themselves. Alternative ways to exit the building should be available and clearly marked, with the doors kept unlocked. Designate a "safe room" which can be locked from the inside and keep a charged cell phone in that room.

Good old-fashioned common sense

Basic things that make a home safe also make a medical office safe. Ice on the walkways outside, loose rugs, bumps in the flooring, uneven door thresholds, doors that are hard to open --  these can all be accidents waiting to happen. Common sense dictates keeping an eye out for potential safety hazards and making repairs as needed.

"Just because it's common sense doesn't mean it's happening," says Bagley. Do a walk-through to look for potentially unsafe situations. Toddler-proof the office even if you don't do pediatrics.

Maintaining a safe environment for patients and staff requires ongoing planning and training, and while some of the suggestions here may seem like overkill for your medical office, it's akin to having good insurance --  you hope you won't ever need it, but if you do you're relieved it's in place and up to date.

Karen Childress, BA, is a certified coach, freelance writer, and healthcare consultant based in Scottsdale, Ariz., with more than 20 years of experience in the healthcare industry. She is the writer and publisher of "Intentions: The Newsletter for Successful Physicians," an e-newsletter for physicians and other professionals. She can be reached at editor@physicianspractice.com.

This article originally appeared inthe March 2005 issue of Physicians Practice.