Joint Commission asks about disaster planning

Surveyors want to know lessons learned

Based on the recent experience of a Massachusetts hospital that underwent its accreditation survey, you can expect your ED nurses to be asked about disaster planning during your next survey.

"They asked about our emergency preparedness plans and our relationship with our local fire department," says Audrey Mears, RN, director of emergency services at Merrimack Valley Hospital in Haverhill, MA." ED nurses told surveyors about their mobile Mass Decontamination Unit (MDU) provided by the state of Massachusetts and their joint training with local firefighters to learn how to set up and operate it. "We also have a good relationship with our Haverhill Emergency Management Agency and meet regularly with them," says Mears.

At 5 a.m. on a Sunday morning, just before the survey by the Joint Commission on Accreditation of Healthcare Organizations, the hospital lost power and experienced generator failure. "We had to alert and mobilize our disaster plan," says Mears. This included placing the ED on "black divert," which means the hospital is closed to all ambulance traffic.

The internal disaster had a major impact on the ED. "We had no power and only emergency phone service," says Mears. "We utilized portable transport monitors that ran on batteries."

Where surveyors spent their time

The surveyors spent a lot of time evaluating the ED's response to this disaster. "The surveyors were most interested in what we learned from the disaster and were quite pleased," she says. "The first lesson we learned was that even with the best assurances and plans that anything is possible — including generator failure and backup generator failure."

They asked nurses how comfortable they were with their emergency preparedness plans, whether they had exercised the plans, and whether they had a way to communicate within the hospital and with their community during a disaster.

During chart review, they looked for the patient's vital signs and pain assessment and looked at the physician's documentation for the patient's condition at discharge. "They asked about patient flow from presentation to triage to inside the care area," says Mears.

The surveyors asked about medication storage and what measures had been taken to prevent errors from look-alike and sound-alike medications.

Carol Warren, an ED nurse who was interviewed by the surveyors, gave the example of the sound-alike drugs dopamine and dobutamine. "Our nurses initiated separating these drugs, as they were originally stored side by side, and put them on separate shelves with improved bold labeling," Warren says. "This was well received by the surveyors."


For more information about the accreditation survey, contact: