The SCAHRM SOURCE Newsletter

Healthcare General Liability Risks

January 2019

By Anne Irving, BS, MA, FACHE, DFASHRM, CPHRM, CPHQ
Director of Risk Management for Premier Insurance Management Services

The scope and complexity associated with providing healthcare services, as well as the heightened vulnerability of patients, may increase the risk of harm when accidents occur. This paper describes commonly observed safety events that have resulted in general liability* claims in healthcare settings. Specific risk management recommendations are also outlined, designed to minimize the likelihood of similar accidents.

Elevators

Different factors have been shown to cause elevator-related events particularly if the involved person is frail or mobility-limited. Case examples:

• The elevator doors lacked a sensing function to recognize that a person or an object was present between them and closed automatically, in some cases reopening upon contact with the person or object. In a few instances, generally involving older elevators, the doors needed to be forced open to release the obstruction.
• A volunteer was pushing a wheelchair with a post-knee surgical patient through the elevator doors, when the doors closed on his operative leg (which was extended in front of him).
• The elevator stopped at a point where its floor was not flush with the building’s floor (it was approximately ¾ below the level of the floor) causing a person to trip as he exited.
• An elevator stopped between floors, entrapping those inside until an elevator technician arrived and could fix it. Although the elevator had an ‘emergency call button’ it did not have means of
  communicating with the persons inside to let them know that help was on the way.
• The elevator door opened up directly across from an open stairwell going to a lower floor. The person leaving the elevator stepped backwards, because she was maneuvering a wheelchair out of the elevator. She fell down the stairwell and was seriously injured.

Risk Management Recommendations:

1. Verify that all elevators are regularly inspected by qualified specialists, to assure proper functioning. If elevator inspections are outsourced – for instance to the elevator manufacturer – a facility engineer should accompany that inspector.
2. Verify that all inspections verify that: a) the time interval set for the doors to remain open is appropriate for persons with mobility limitations; and b) the sensor mechanism in the doors (that perceives if something is in the space between the open doors) is operating properly. Discussion: All elevator doors should have a built-in visual sensor system that automatically reopens the doors when a person or object is in the space between the doors. Those that only open if the door physically hits an obstruction pose a risk of entrapment, falls or other injuries.
3. Post the most recent inspection certificate in each elevator, so the date of the most recent inspection is available to all. Also verify that the emergency call system in each elevator is functional and that calls are directed to a number that is answered 24/7.
4. Install a barrier at the top of an open stairwell if an elevator opens directly opposite from it.
5. Maintain documents pertaining to elevator inspections, service requests and completed work orders. In the event of an accident involving an elevator, such records may need to be produced.
6. Reconsider the policy of allowing volunteers to transport patients to the hospital entrance at the time of discharge, particularly if the patient’s mobility is restricted or he/she is wearing a cast, brace or prosthesis. A volunteer, for instance, may not understand that a patient was advised to refrain from bearing weight his post-operative leg, whereas a nurse would be cognizant of such limitations when assisting the patient into a vehicle.

Automated Doors:

Healthcare organizations often install doors that open automatically, as an accommodation for seniors and persons with disabilities. Injuries may occur while someone is moving through such doors, as illustrated by these cases:

• An elderly woman using a walker to enter the hospital paused to catch her breath between the two open doors. The doors closed on her, causing her to fall and fracture her hip. The doors were motion-activated and did not have any type of sensor to determine if a non-moving person or object was in the space between them.
• A man in a wheelchair pushed the pressure plate outside the entrance to open the door. While in the process of entering the door closed and struck him. The timing mechanism was set to remain open for a limited number of seconds and there was no visual sensor in place that could identify that a person or object was present in the doorway.

Risk Management Recommendations:

1. Identify the frequency of routine inspections of all such doors, particularly the functional status of the embedded sensor mechanisms. Verify that such inspections test those mechanisms by placing objects between the doors to identify if the door remains
   open.
2. Ask the inspector to also monitor the time interval that has been set, for the door(s) to stay open (even if nothing is between the doors). With the cohort of senior citizens ever-growing, this time interval may need to be increased, to allow older, frail, or physically-challenged persons more time to enter/exit. Similarly, the time set for traffic lights needs to allow sufficient time for pedestrians to cross the intersection.
3. Add a second sensor function to doors that currently only have a motion-activated mechanism.
4. Post something on each glass door at eye level, so that the door is not all glass. For persons with low vision this helps to identify that it a door and not an open space.

Furnishings:

As in any building, objects may fall down and/or furniture may break. Case examples from healthcare organizations include the following:

• A large, freestanding display board in the waiting area of an emergency department was bumped and fell over on a child in an emergency department waiting room.
• A shelf, picture on the wall, ceiling tile, and window blinds accidently detached and fell.
• An exercise ball used in Rehab broke while a patient was sitting on it.
• A chair in a waiting area broke when a heavy person sat down in it.
• A child played with a rolling stool in an exam room (intended for use by the provider) and fell off.

Risk Management Recommendations:

1. Verify that the scope of your organization’s environmental safety rounds includes periodic inspection of: ceiling tiles, artwork, shelves, light fixtures, furniture, etc.
2. Prohibit the use of freestanding screens or displays.
3. Prohibit the use of rolling stools, or only permit stools that have an auto-locking function when a person sits on them.
4. Verify that staff responsible for cleaning perioperative or procedure rooms also inspect fixtures and furnishings to identify possible safety issues.
5. Collaborate with facility, design, and environmental managers to
   assure all patient care areas and waiting areas have seating (e.g. benches, loveseats) that are suitable for heavy persons.
6. Discretely note the manufacturer’s maximum weight limit on all furniture, exam tables, scales, rehab devices, etc. (e.g. Note “350” on the underside of the item.)

Flooring:

Wet floors are a factor in many GL fall events. During inclement weather, persons who enter the hospital may track in snow, or water. Other falls have been caused by: frayed carpeting, use of the wrong floor polish, spillage from drinking faucets, or improper floor cleaning practices.

Uneven floors, such as those on a slight incline, may also cause falls if the level change is not readily apparent. Carpeting with has a complicated pattern may also impair perception of level changes. Although a textured, bright yellow surface is often observed on sidewalk ramps at intersections, a 2013 study (1) found that a coarse texture pattern on the ground plane can hinder visibility of ramps and steps under low-resolution viewing conditions.

Risk Management Recommendations:

1. Increase facility/housekeeping surveillance of all entrances during periods of inclement weather, so that excess water or puddles can be promptly addressed. Assure that absorbent floor mats are placed at all entrances. Also place ‘wet floor’ signs in those areas.
2. Place plastic umbrella bags at all entrances, such as the type shown above.
3. Verify all floor cleaning and polishing agents are “non-slip”.
4. Require personnel to wash one side of a hallway at a time, in order for the other (dry) side to be fully usable. Place multiple signs indicating all of the areas that are wet.
5. Place ‘spill kits’ throughout the facility, which should include clean up materials and pop-up ‘wet floor’ signs.
6.  Include drinking fountains in environmental safety rounds, to check that the water pressure setting does not cause excess spillage.
7.  Educate staff about how to assist a person after he/she has experienced a fall, whom to call if the person appears to require immediate medical treatment, and how to report this event (and follow-up services offered or provided). In addition to the facts about the fall itself, staff should note in their report any observations that may be relevant, e.g. the woman who fell was wearing high heeled shoes and had just entered the lobby from the snow-covered parking lot.
8. Refrain from using ‘busy’ patterned carpeting.

Warming Cabinets:

Various types of warming devices or cabinets are used in hospitals, such as blanket warmers, blood warmers, and IV fluid warming cabinets. Misuse of these devices can lead to patient harm, as illustrated by the following cases:

• Patients experienced burns due to:
  • The blanket warming cabinet temperature was too high- 200 F;
  • An intravenous (IV) fluid bag of saline was heated in a manner that was not approved by the hospital’s policy: in one case it was heated in a blanket warming cabinet and in another case a microwave oven was used. Note: Even after removed from a microwave oven, the item continues to ‘cook’ for a period of time. (2)
• A nurse placed a ‘sand bag’ (designed for patient positioning) in a microwave over to heat, intending to use it for patient warming. Unbeknownst to her, the bag was filled with metal beads – not sand – which triggered a fire (contained to the oven).

Discussion: Irrespective of whether a warming cabinet’s manufacturer permits a higher temperature setting, ECRI recommends that IV warming cabinets be set no higher than 110 F, and blanket warming cabinets no higher than 130 F (54 C). (3). Microwaves should never be used for warming blankets, IV fluids or other patient-care related items.

Risk Management Recommendations:

1. Establish formal, written policies that:
   1. Stipulate that only blankets and devices marketed for warming purposes (e.g., forced air garments, heating pads) may be used to help a patient feel warmer;
   2. Prohibit the use of warmed IV bags of fluid for patient warming;
   3. Prohibit the use of a microwave oven for warming any item intended for patient use: IV fluids, blankets, sand bags, or other treatment-related items;
   4. Specify that the maximum temperature setting for all blanket warming cabinets shall be set no higher than 130 degrees F, with a sign placed them noting that limit; and
   5.  Specify that the maximum temperature setting for all IV fluid warming cabinets shall be set no higher than 110 degrees F, with a sign placed on them noting that limit.
2. Verify that the scope of the organization’s environmental or facility safety rounds includes inspection of all warming cabinets to assure compliance with the above policy.

Compressed Oxygen:

Oxygen (O2) is a highly flammable gas. In addition, if a cylinder is dropped in a way that affects its valve, it forcefully self-propel (referred to as the “missile effect”). While transporting a patient who requires oxygen, staff must use an approved means of transporting the portable O2 cylinder. The following are examples of unsafety practices regarding portable O2 cylinders:

• Empty and full O2 cylinders were stored in the same area;
• Full O2 cylinders were observed standing vertically on the floor, without
  being secured;
• A portable O2 cylinder ran out of O2 while a patient was in transport;
• The O2 cylinder attached to a crash cart was nearly empty (because the crash cart checking process was sporadic);
• A portable O2 cylinder was placed horizontally, laying down beside the patient on a stretcher, while transporting the patient. When the patient arrived in the inpatient room, the O2 tank accidently fell off the stretcher, struck the floor and “shot through” the ceiling into the room immediately above. (Fortunately no one was injured.)

Sidebar – OSHA Regulation 1910.253 (Excerpt)

(b)(2)(ii) “Inside of buildings, cylinders shall be stored in a well-protected, well-ventilated, dry location, at least 20 feet (6.1m) from highly combustible materials such as oil or excelsior. Cylinders should be stored in definitely assigned places away from elevators, stairs, or gangways. Assigned storage spaces shall be located where cylinders will not be knocked over or damaged by passing or falling objects, or subject to tampering by unauthorized persons. Cylinders shall not be kept in unventilated enclosures such as lockers and cupboards.” (4)

Risk Management Recommendations:

Verify the organization has policies and procedures in effect which:

1. Comply with National Fire Protection Agency, U.S. Occupational Safety and Health Administration (OSHA), state and local regulations and pertinent professional associations’ recommendations, such as the Compressed Gas Association.
2. Require the person selecting an O2 tank level for use during patient transport to check the O2 level in the tank, and select one that shows a volume of not less than 50%;
3. Specify the minimum number of full portable 02 tanks that must be available on each unit.
4. Specify who is accountable (by position) for monitoring the O2 tank inventory on each unit, including ordering additional supply, when indicated;
5. Outline key specifications concerning how O2 cylinders are stored, including that it be stored (this list is not all inclusive):
   • In a locked, ventilated room, with the appropriate hazard warning sign on the door
   • Only with other compressed gases if they are of the same hazard class
   • Must be stored in upright position at all times (including empty ones) [OSHA 29 CFR 1926.350(a)(9)]
   • In an area that is without any items containing oils or grease (5). [OSHA 1926.350(j)]
   • In a secure manner, such as:
     • Placed in a box constructed for this purpose, with a designated chamber for each cylinder; or
     • With the cylinders stood up vertically on the floor, adjacent to each other, with a metal chain securing each cylinder –or all of them as a group – to the adjacent wall.
6. Specify the proper manner for securing portable O2 cylinders while they are in transit, such as by:
   1. Placing the cylinder in the trough underneath the stretcher (if there is one) and tied down;
   2. Placing it in a metal O2 cylinder holder that is affixed to the bedframe, wheelchair or stretcher;
   3. Using a wheeled trolley that is specifically designed to carry a portable O2 cylinder; The policy should explicitly prohibit laying an unsecured O2 cylinder on a: bed, stretcher, flat shelf underneath a stretcher, patient’s lap while sitting in a wheelchair.

Magnetic Resonance Imaging (MRI) Services:

The magnet in a MRI unit is extremely powerful, causing any ferrous-containing object that is within range to be forcefully drawn into the machine. To help identify the areas of greatest risk, the American College of Radiology (ACR) has defined 4 ACR Safety Zones (5) within a MRI suite (see below). Zones I and II are near the entrance to the suite (where registration occurs); Zones III is the area where patients get ready for the exam; and Zone IV is the area that houses the MRI unit. MRI personnel are required to undergo extensive training about the unique risks of an MRI suite.

The ACR has also issued a wide array of other MRI safety guidelines (6); several will be highlighted in this section. “MRI safe” equipment must be purchased for use in this area, e.g., those made of nonferrous materials. These include (but are not limited to): Fire extinguishers, stretchers, wheelchairs. Those made of nonferrous material need to be labeled accordingly.

When a mobile MRI unit (in a truck) provides services in lieu of hospital-based MRI services, there are additional safety issues to consider, including (but not limited to):

• Do members of the hospital’s rapid response, code and fire response teams know the location of this mobile unit?
• Does the mobile unit have its own MRI-safe fire extinguisher and MRI-safe code resuscitation equipment?
• What is the means of patient access to the mobile unit from the hospital, is it accessible to persons with mobility issues?
• Are the appropriate warning signs posted in the vicinity around where the mobile unit is stationed?

Accidents that have occurred in an MRI suite include:

• Staff used “sand bags” to help position the patient, and did not realize the bags were actually filled with metal granules, not sand.
• A fire response team member entered Zone IV carrying a regular fire extinguisher. It was drawn in to the MRI core, because it contained ferrous material and was not “MRI safe”. The patient who was lying in the MRI was struck by the fire extinguisher and injured severely.
• Objects made of ferrous materials (jewelry, items in employees’ pockets) have been sucked in to the MRI unit.

Risk Management Recommendations:

1. Stay abreast of industry recommendations regarding MRI safety (see references) and refer to them when developing and updating MRI policies.
2. Conduct periodic risk assessments of this suite (and/or each mobile MRI unit), including a tour, policy/procedure review, analysis of safety event reports and close calls and interviews with frontline and MRI management staff.
3. Verify appropriate signs are posted that demarcate each of the Zones in the MRI suite and state “Authorized Persons Only”. Some facilities also paint stripes on the floor indicating where Zones III and IV begin.
4. Consider building a metal detector into the doorway or entrance to Zone III, or passing a handheld metal detector over all items/persons before they are allowed to enter Zone III.
5. Verify all equipment and devices used in the suite are nonferrous, and each is labeled “MRI Safe”.
6. Implement a mandatory training program for all personnel who respond to codes, fires, and other emergencies (including clinical responders, facilities management and plant engineering staff) to instruct them about the unique characteristics and risks of the MRI suite. Track attendance at those training programs by new hires, outside vendors/contractors, residents, etc. Consider requiring annual ‘refresher training’ for all MRI suite staff and others who may periodically need to enter the suite.
7. Assure that when a patient experiences a medical emergency while in Zone IV, MR staff remove him/her from that Zone before resuscitation efforts begin, when possible. By being out of Zone IV, it will present fewer barriers to member of the code team.
8. Require MRI staff members whose roles involve providing services in Zones III or IV:
   1. To complete specialized training prior to being allowed to work in those zones;
   2. To wear a designated scrub suit (of a unique color not used elsewhere in the hospital) after they complete the above training.
9. Require all staff who intend to enter Zone III or IV to change into (different colored) MRI-only scrub suits.
10. Require patients and other staff who have not completed the specialized Zone III-IV training to be accompanied by a MRI Zone III-IV trained staff person, at all times, whenever he/she is present in Zone III or IV.
11. Report all instances that do not conform to these policies via the organization’s safety event reporting process, including close calls, and irrespective of whether the MRI unit or a patient or staff person appeared to sustain an injury.
12. Perform code and fire drills periodically in the mobile MRI unit and/or the main MRI suite.

Sidebar: Enforcement of safety policies

A resident tried to enter Zone III of a MRI suite. MRI staff informed her that by policy, anyone intending to enter Zone III or IV must change into the “MRI scrub attire” (only available in that department). The resident was wearing another type of scrub suit, covered by a lab coat; she patted her pockets, and said “I don’t have time to change, see… my pockets are empty” and proceeded to enter Zones 3 and 4. Nothing adverse occurred. MRI staff reported this safety violation, per organization policy. Medical staff leadership suspended the resident for 1 week based on the finding that she willfully violated an established safety policy.

Decorative Water Features, Ice Makers, Drinking Faucets, and Air Conditioning Systems:

There have been reports of pathogens such as Legionella being found during inspections and testing of decorative water features, ice machines, drinking faucets, sinks and air conditioning systems. Such pathogens pose a health hazard, particularly to immunocompromised persons and/or those with chronic health conditions.
In 2012 and 2013 several outbreaks of Legionella occurred in hospitals in Pennsylvania (7), which were tracked to ice makers. In 2016, a Seattle hospital (8) identified this pathogen in two sinks and an ice maker on its cardiac unit.

Risk Management Recommendations:

Assure that Facility Engineers are aware of the most current ANSI/ASHRAE (9), and Centers for Disease Control and Prevention (CDC) guidelines (10) and update organizational policies, procedures and practices to be consistent with them.

1. The heightened risk of infections faced by patients treated in cancer
   centers, oncology units and infusion centers may warrant more rigorous interventions, such as:
   • Purchase of ice machines which feature more advanced water purification mechanisms;
   • Installation of water filters on drinking faucets and showers in patient rooms;
   • More frequent inspections;
   • Removal of decorative water features.
2. Verify the preventative maintenance procedures that are followed are specific to the manufacturer’s recommendations for each ice machine model, water feature and air conditioning system. Discussion: There are often different maintenance procedures depending on the make or model of ice maker, water feature and air conditioning system. Testing must include all parts and materials: In one case involving a decorative water feature, the water samples were negative, but the foam material in the fountain tested positive for Legionella.
3. Verify periodic testing of these items includes testing for possible pathogens, irrespective of
   whether the manufacturers of those items require such testing. Such testing should include samples from all parts and materials associated with each device*.
4. Maintain documentation of preventative maintenance services performed as well as the results of all tests/inspections.
5. Verify that clinicians advise immunocompromised patients of their heightened risk to infections, and encourage them to avoid exposure to decorative water features.

Parking Lots, Garages, and Grounds:

The organization has an obligation to design and maintain its grounds and buildings in a manner that promotes safety. This includes (but is not limited to): inspecting and maintaining all trees, landscapes, exterior features, fences; providing adequate lighting; taking prompt action to repair damaged road surfaces, parking lots or garages, sidewalks, etc.

Examples of safety issues involving the grounds and parking structures include:

• Inadequate traffic signage, leading to accidents because of poor visibility and multiple points of access to a parking garage;
• Potholes or severely cracked payment or asphalt;
• Low slung chains (suspended between vertical posts) used instead of solid wood or chain-link fencing materials;
• Inadequate snow or ice removal or remediation (salt/sand);
• Inadequate lighting and/or failure to replace burned-out bulbs;
• The lack of or inoperable status of an emergency call system in a parking garage;
• Failure to maintain trees on the property (limb of a diseased tree falls on a car);
• Open access to ponds or lakes on the property;
• Aggressive wildlife on the property (e.g., Canadian geese during nesting season);
• Paint spattered on a visitor’s car when a facilities staff member was painting a nearby fence.

Risk Management Recommendations:

1. Verify Facilities Management staff regularly inspect the grounds and buildings, to identify and address maintenance issues (with increased frequency of these inspections during inclement weather).
2.  Indicate the edge of all steps with a colored line, to enhance visibility.
3. Paint stripes (or install textured features such as raised bumps) on surfaces that are uneven or sloping, such as ramps intended for wheelchairs.
4. Install speed bump to slow traffic, and place highly visible stop signs at problematic intersections in parking lots.
5. Refrain from using chains as a fencing material.
6. Modify landscaping in close proximity to the buildings in order to make it less hospitable to wildlife.
7. Post signs near any ponds on the property indicating that ‘access/swimming is prohibited.’
8. Consider installing video-camera monitoring in parking garages, and/or installation of an emergency call system. If these features are installed, regular checks should be performed to verify their functional status. Discussion: Hospitals in urban areas or areas with a high crime rates should consider the usefulness of such interventions.
9. If the organization sub-contracts certain functions (e.g. snow removal) a hospital manager must be assigned oversight accountability in order to assure that the contractor’s services are timely and effective.

SUMMARY

The severity (average indemnity payment) of professional liability (PL) claims in healthcare organizations is significantly greater than the severity of general liability (GL) claims. Nonetheless, it is useful for risk managers to review all reports involving GL events so that they can facilitate corrective actions, as warranted. Proactively, it is also important that those who conduct environment of care safety inspections are aware of the type of vulnerabilities associated with property, grounds and building design features.

This article outlines a wide range of GL safety risks, based on real cases. Risk managers are encouraged to share this article with appropriate stakeholders, such as (but not limited to) leaders in the following domains: facilities management, engineering, safety, security, housekeeping, radiology, nursing, and other department managers. An Environment of Care Safety Self-assessment is also provided below.

Author Notes: The inclusion of a photograph or cited resource does not imply nor should it be construed as an endorsement by the author or her employer. The author wishes to thank several of her colleagues who reviewed this article: Margaret Douglass, Adrienne Prager, and Les Meredith.

Claim data supporting the scenarios in this article are from American Excess Insurance Exchange, RRG (AEIX), a Vermont reciprocal risk retention group providing professional liability and general liability excess insurance to member hospital systems and their providers across the United States. WWW.AEIXRRG.COM

About the Author

Anne Irving, BS, MA, FACHE, DFASHRM, CPHRM, CPHQ holds the position of Director of Risk Management for Premier Insurance Management Services, a subsidiary of Premier Inc. Ms. Irving has a clinical background and has held leadership positions in medical affairs, quality improvement and risk management (RM) in acute care hospitals. More recently she has worked as a risk management consultant for several malpractice carriers, and as a patient safety officer for a large integrated delivery system.

Ms. Irving has served as an examiner for the Baldrige National Quality Award program and has published articles on a variety of topics in peer-reviewed journals including: Trustee, Journal of Healthcare Risk Management (ASHRM), Patient Safety & Quality Healthcare.