Becker's Clinical Quality & Infection Control

8 INFECTION CONTROL & PATIENT SAFETY Patient suicide linked to safety issues at Florida VA hospital, OIG finds By Mackenzie Bean S eniors leaders failed to promptly address "long-standing deficient conditions" and safety concerns at West Palm Beach VA Medical Center, which may have contributed to a patient's suicide in early 2019, according to an Aug. 22 report from the VA Office of Inspector General. OIG inspected the Riviera Beach, Fla.-based hospital aer the incident and found the patient received "reasonable care" while admitted to the facility's locked inpatient mental health unit. However, investigators found numerous deficiencies in staffing, employee training and risk mitigation on the unit. Cameras the hospital was required to have on the unit for patient safety reasons hadn't worked in three years. In addition, staff members failed to properly conduct the required safety checks every 15 minutes on admitted patients, inspectors found. "Overall, the OIG found that facility leaders lacked awareness of patient safety require- ments and related issues on unit 3C and appeared to accept inaccurate explanations for noncompliance and unsafe conditions," OIG wrote. e medical center completed a "thorough review" of its mental health unit aer the incident and is implementing a corrective plan based on nine recommendations from the OIG, according to Miguel LaPuz, MD, director of the St. Petersburg, Fla.-based VA Sunshine Healthcare Network. "We appreciate the Office of Inspector General's oversight, which focuses on an event that occurred in March 2019," the VA said in a statement to Becker's. "Any time an unexpected death occurs at a VA facility, a comprehensive review is conducted to see if changes in policies and procedures are warranted. OIG reviews are opportunities to strengthen our processes and the way we deliver care to America's veterans." "Additionally, we continue to reinforce edu- cation to all staff and maintain suicide pre- vention as a priority. As part of our ongoing structural improvement plan, we continue to make upgrades to all areas of the hospital to provide the safest environment for our patients, visitors and staff," the VA said. n Hundreds sickened by duodenoscopes: Experts demand change By Anne-Marie Kommers H undreds of patients in the U.S. and Europe have been sickened by infections transmitted through duodenoscopes, prompting medical experts to urge the Food and Drug Administration to force manufac- turers to improve the devices or take them off the market, according to The New York Times. More than half a million duodenoscope procedures are performed in the U.S. each year to diagnose and treat diseases in the pancreas, bile duct and gallbladder. Yet recent tests, performed by manufacturers at the demand of the FDA, found one in 20 devices still contain microbes like Escherichia coli after proper cleaning, a ratio far worse than anticipated. Hundreds have been infected in dozens of outbreaks linked to duodenoscopes since 2012, including outbreaks of antibiotic-resistant bacteria. Most duodenoscopes are manufactured by Olympus Medical Systems Corp., Pentax of America and Fujifilm Medical Systems USA. They claim that following their cleaning and disinfection instructions make the devices safe for patients. n Second Ben Taub patient found dead in bathroom By Mackenzie Bean A second patient was found dead in a bathroom at Houston-based Ben Taub Hospital after waiting for emergency care, according to the Houston Chronicle. The death occurred July 16, just three months after staff members found a 66-year-old patient unrespon- sive with no pulse in an emergency department bath- room. Ben Taub reported the second death to CMS and the Texas Health and Human Services Commission July 19. "Incidents like this should never happen," George Masi, president and CEO of Houston-based Harris Health System, which operates Ben Taub, said in a statement to the Houston Chronicle. "It is our responsibility to learn from them, and to constantly make improvements in our processes to ensure Harris Health fulfills our mission of caring for those most in need. We are fully committed to that effort, whatever it takes." Mr. Masi said Ben Taub investigated the death and immediately implemented "additional risk reduction strategies" to ensure patient safety. n

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