What is a Sentinel Event?
The Joint Commission defines sentinel events as occurrences to patients in medical facilities “…involving death or serious physical or psychological injury, or the risk thereof." As you will note from the pie chart above, patient suicides are a comparatively frequent sentinel event identified by The Joint Commission. The Door SwitchTM was developed to mitigate the most common method of suicide employed in medical facilities—hanging using a door as a ligature point.
Please visit The Joint Commission for more information on sentinel events.
The Door SwitchTM is the original top-of-the door ligature attempt warning system and holds U.S. Patents RE 42,991 and RE 44,039. We have been serving mental health professionals since 2006.
Each Door SwitchTM is a pressure sensor activated by approximately one to two pounds of downward pressure applied to the top, rather than the face (front or back surfaces), of the door. With system activation at the top of the door, ligature devices applied from either side of the door result in system alerts. Hospital staff are notified of system alerts by a combination of audible alarms, strobes, and door identification provided at a keypad typically located at a nurses’ station. The system utilizes proven Honeywell electronic components, including the Honeywell Vista 128BPT panel as the controller.
The Honeywell Vista 128BPT control panel provides an event log that records the times and dates of 512 events. The controller records the application of pressure to one of the system’s Door SwitchesTM, the removal of that pressure, and the turning of a key switch to silence the alarm. Logged events can be viewed from the keypad or downloaded to a computer and printed.
The Door SwitchTM has been installed in mental health facilities across the country. We are proud to state that we have many satisfied mental health facility clients and can provide you with their contact information for reference purposes.
For additional information, a demonstration of The Door SwitchTM, or a free quote, please call or email us.
Separating Fact From Fiction In Hospital Facilities
ASHE Expert Explains Observations in Various Health Care Settings
We all know the facts. Patient suicide in health care facilities is preventable. But, it still occurs. In addition, the suicide rate has increased more than 25 percent nationwide from 1999 to 2016, according to the Centers for Disease Control Prevention report. Most of these inpatient suicides are a result of hanging in a bathroom or bedroom by using a part of the door.
American Society for Healthcare Engineering (ASHE) expert, Chad E. Beebe AIA, CHFM explains some lesser-known facts about what hospitals are required to do to decrease the occurrence of these tragic events. He states that many health care organizations are misinterpreting the requirements for reducing ligature risk. While reducing risks in the physical environment is important, these safeguards come second to continuous one-to-one (1:1) observation of any patient with suicidal ideation in a general hospital setting.
He states that the “eyes have it” and “visual monitoring — especially observations conducive to 360-degree viewings by a paid sitter in the room assigned to one patient provides little room for error” and “there’s no substitute for human eyeballs and the ability to immediately intervene when suicidal thoughts change to a suicidal attempt.” The Centers for Medicare & Medicaid Services (CMS) published a clarification to this rule in December 2017: “Psychiatric patients requiring medical care in a nonpsychiatric setting (medical inpatient units, ED, ICU, etc.) must be protected when demonstrating suicidal ideation or harm to others. The protection would be that of utilizing safety measures such as 1:1 monitoring with continuous visual observation, removal of sharp objects from the room/area, or removal of equipment that can be used as a weapon.”
What Beebe is trying to clarify is that with all the new changes and upgrades to patient care, it’s important to know the specific rules and to which facilities those rules apply. For instance, he states: "In a general hospital setting or emergency room setting, if a person in the hospital can watch one assigned at-risk patient unceasingly, the only hazards that need to be removed are anything that could quickly be used to inflict harm. That means taking away items like glass flower vases, pens and sharp eating utensils. It doesn’t require major changes to the physical environment like eliminating grab bars, sink drain pipes or door hinges, or installing over-the-door sensors."
In an acute mental health inpatient facility and situations where this level of observation is not possible (as is often the case in psychiatric hospitals), ligature-resistance steps need to be taken instead.
Beebe also recommends following the same action steps American Society for the Health Care Engineering’s (ASHE’s) three-step ligature-risk guidance for general acute care or emergency departments (EDs), by using helpful checklists and tools available and learning more about this topic.
To learn more about these checklists and read this entire article, click here.
The Door Switch wants to continue the fight for more awareness and provide additional resources to dispel the myths about mental health issues and solutions for safety issues. We also continue to strive to provide a product that keeps the hospital environment safe. We continue to be committed to better practices and procedures in mental health community. For information concerning our safety product, please click here.
The Door SwitchTM