ERM-BC-COOP: Policies & Procedures

Create BEFORE need

 

Lack of relevant policies and procedures is likely to cost the University of Toledo Medical Center (UTMC) at least US$25,000.

According to Lawyers and Settlements.com, a 30-year veteran nurse at UTMC was terminated for failure to stop another nurse from removing items from the operating room before the procedure had concluded. The complaining nurse claims she was also fired for violating policies on communications and logging out.

The story is that the plaintiff was working in the operating room (OR) with another nurse.

The other nurse left the OR for lunch, but, according to the article, failed to log out of the hospital computer system. Returning from lunch the nurse allegedly disposed of a kidney that was waiting to be transplanted.

The plaintiff contends

• that she had not witnessed the removal of the items and was unaware they had been removed after the other nurse had returned from her break, and
• that the policies and procedures to prevent such incidents were implemented days after the fact

Could policies and procedures - P&Ps - have prevented the Case of the Disappearing Kidney?

By themselves, unlikely. The article suggests the other nurse violated P&Ps (to log out of the hospital computer system) so at least one person disregarded published policies and procedures. It is possible, but based on the article likely NOT the case, that there was a policy and procedure to identify organs to be discarded.

In addition to the dismissed nurse’s suit, UTMC also is being sued by the family of the person who was supposed to receive the donated kidney.

If, then, P&Ps by themselves are not enough, what can be done to assure they are followed.

As with most things ERM, training, training, and more training, coupled with management flag waving to convince all personnel the reasons for, and the importance of, policies and procedures.

Having effected staff review, and comment on, relevant policies and procedures at least annually enhances awareness while giving the personnel a feeling of ownership.

 

If I wrote it, you may quote it.

ERM-BC-COOP: Y-12 . . . again

 

No performance checks?

Once again the Y-12 Tennessee nuclear arms facility's security has been breached.

This time by a little old lady who apparently was got lost.

According to an article on the KnoxNews Website (http://tinyurl.com/ksj8x6f), The security breach occurred less than a year after three protesters cut through a series of security fences and walked to the innermost sanctum of Y-12, the country’s largest repository of weapons-grade uranium.

“I’m not aware of any circumstances quite like this,” said Steven Wyatt, spokesman for the National Nuclear Security Administration and Y-12. He called Thursday’s incident a “security lapse.”

The woman who got onto the secure property told police she was searching for a new low-cost apartment complex she’d seen advertised. She followed a large throng of morning commuters shortly after 6 a.m. Thursday and was waved through Y-12’s main entrance off Scarboro Road, according to the report.

According to the Energy Department's Y-12 Web presence, "Y-12's core mission is to ensure a safe, secure, and reliable U.S. nuclear deterrent, which is essential to national security.

"Every weapon in the U.S. nuclear stockpile has components manufactured, maintained or ultimately dismantled by Y-12, the nation’s Uranium Center of Excellence. We employ only the most advanced and failsafe technologies to protect the stockpile."

Y-12 claims that "We train nuclear industry professionals, emergency responders and security forces from around the world to safeguard vulnerable materials; and the innovations engineered at Y 12 have applications for allies, other government agencies, and the private sector."

How successful Y-12 is at safeguarding its own "vulnerable materials" has to be questioned in light of a recent "invasion" by three protesters. A New York Times article headlined "The Nun Who Broke Into the Nuclear Sanctum" notes that on July 28, 2012, "Sister Megan Rice, 82, a Roman Catholic nun, and two male accomplices, one 63 and the other 57, carried out what nuclear experts call the biggest security breach in the history of the nation’s atomic complex, making their way to the inner sanctum of the site where the United States keeps crucial nuclear bomb parts and fuel." (http://tinyurl.com/bzdd7n6)

The KnoxNews article reported that "Guards at Y-12’s entrances are supposed to inspect and at least touch an employee’s Y-12 security badge before handing it back."

It would seem that the policy and procedure to prevent the latest excursion into the "secure" facility were in place, but they were never exercised, tested under stress - that is, rush hour at the gates.

While most practitioners don't have similar security concerns, the lesson to be learned from the on-going security fiasco at Y-12 is that resources on which the organization depends also are at risk during a "rush hour." Communications is a primary example.

Actually just getting people into work can be a risk. (Staggered start times can help, but keep in mind the roadway infrastructure leading to the facility; do the neighbors also have the same start times?)

It behooves practitioners to consider "weak links" and to test those links' robustness.

Are there work-arounds in place - off-site hoteling and home office when the roads are jammed, alternate phone options, especially if Internet services are carried over the same fibre as voice calls.

While you are at it, check to see just how secure is the facility.

If I wrote it, you may quote it