Purchasing for Patient Safety
A hand sanitizer dispenser developed specifically for the inpatient mental health environment.
One trademark of a High-Reliability Organization (HRO) is a preoccupation with failure. An HRO is always thinking about what could go wrong. The VA National Center for Patient Safety (NCPS) was founded on this and other key principles of high-reliability science. Ensuring patient safety for our Veterans starts long before a patient is seen at the bedside.
NCPS collaborates with the Food and Drug Administration (FDA) and other stakeholders before products enter the VA supply chain. NCPS’s involvement has eliminated potential hazards before they reach the patient or providers. One such example started as a discussion between the NCPS Human Factors Engineering (HFE) team and a leading skin health and hygiene solution company. This dialogue was the genesis of a hand sanitizer dispenser built specifically for inpatient mental health units; it became the first hand sanitizer dispenser to receive support for use in high-risk areas by the New York State Office of Mental Health,1 which provides the gold standard for mental health environmentalproduct testing.
Although death by suicide in VA inpatient mental health units is extremely rare (0.74 per 100,000 admissions)2, the leading cause of those deaths is by hanging. Thus, over the past 10 years, VA has been aggressive in identifying and removing ligature points from inpatient units through the use of the highly-detailed Mental Health Environment of Care Checklist (MHEOCC). NCPS’s involvement in the company’s development process led to the inpatient hand sanitizer dispenser featuring an anti-ligature design. The design reduces the risk of hand sanitizer units being used for self-harm.
A key component of the Veterans Health Administration’s (VHA) journey towards high reliability is the ability of NCPS and other VHA offices to recognize potential hazards before they enter the supply chain to ensure that the products used are safe, reliable and efficient.
References
1. New York State Office of Mental Health. (2017, January 13). Patient Safety Standards, Materials and Systems Guidelines Recommended by the New York State Office of Mental Health. Retrieved April 14, 2017, from New York State Office of Mental Health: https://www.omh.ny.gov/omhweb/patient_safety_standards/guide.pdf
2. Watts, B. V., et al: (2017, April 1). Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services, Vol. 68(No. 4), 405-407.
