JOHNSON CITY, TN (WJHL) – The organization in charge of accrediting Mountain States Health Alliance is now aware of an 89-year-old woman’s fall inside an operating room at Johnson City Medical Center.
Melba Lowe’s daughter said she recently mailed The Joint Commission a letter, along with pictures of her mother’s injuries. Among other things, the letter said it took a year for the family to find out why her moderately sedated mother fell during a routine endoscopy in July 2016.
“I just want them to check into it to make sure that they feel like everything was done that could be done and that there’s a procedure in place now that would ensure the safety of the patients,” Karen Mazzei said.
A MSHA spokesperson said the health system is not required to report falls to The Joint Commission and did not in this case, but did report the case to MSHA’s governing board’s quality committee.
Once a complaint is received, The Joint Commission reports it immediately directs its Office of Quality and Patient Safety involved to determine what action is necessary.
While a spokesperson told us all complaints are confidential, she added depending on the nature of the situation, the organization could initiate one or more actions if the complaint relates to a Joint Commission standard.
“The Joint Commission’s evaluation then focuses on assessing the organization’s overall compliance with those standards and following up to verify that improvements have been made to prevent a similar incident or situation,” Katie Bronk said.
Bronk said possible actions include:
• If the situation raises concerns about a continuing threat to patient safety or if it suggests a failure to comply with Joint Commission standards, then The Joint Commission may conduct an unannounced or unscheduled on-site evaluation of the organization.
• The organization may be requested to provide a response to the concern.
• If the organization is scheduled for its routine accreditation survey or certification review in the near future, then the organization’s compliance with related standards may be reviewed at that time.
• The details of the concern are incorporated into a database used to monitor patient safety and quality issues and track trends at Joint Commission accredited or certified health care organizations.
• Failure to comply with the standards may potentially adversely affect an organization’s accreditation status.
• In some instances a patient safety event is determined to be a sentinel event and is then reviewed by the Sentinel Event Unit within the OQPS in accordance with the Sentinel Event Policy (requires immediate investigation and response)
MSHA CEO Alan Levine said not only is the health system now better prepared to prevent this kind of fall in the future, The Joint Commission reviews that process to make sure the health system follows it.
“We have a process to make sure there’s an investigation, there’s corrective action and that our governance is notified of what occurred and what was done to make sure it was corrected,” Levine said. “I feel really good that we do do that pretty well.”
Levine confirmed someone looked away from Lowe in the moments before she fell. Mazzei said in recent weeks, hospital staff assured her OR staff will not take their eyes off of patients in the future.
“They did tell us that from now on someone will be standing right there at the patient and will not turn away,” Mazzei previously said.
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