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2807 Samoset Road, Suite 200,
Royal Oak. MI 48073.
There is more to everything than meets the eye. Take, for instance, a tree. One thick piece of wood, smaller sticks attached, then leaves at the end. Pretty simple, right?
Now, take a moment to consider the inner workings of the tree: xylem, phloem, chlorophyll, and the chemical reaction generating life-affirming glucose and releasing oxygen back into the atmosphere. Not so simple after all. And you can dig down even further, until you end up with protons, neutrons, and electrons. Change those and you have something altogether different.
Patient Safety is similarly complex. When viewed from afar, it is: “our patients are safe”. Closer in, it becomes: “we prevent self-harm, accidental falls, suicides, and hospital acquired infections.” Closer again, and it becomes: the type of disinfectant, building layouts, staff engagement, maintenance procedures — the list goes on. It is a great example of fractals; viewed from afar, it seems complete, but there is always a further level of detail. Add in the human factors and statistical variables, and you have a considerable challenge on your hands.
However, as the old saying goes: a long journey starts with a single step. A complex issue like patient safety is similar. Dig deeper and take a look at the contributing factors. Perhaps patient falls occur during the night. Would a night-light help? Or in the bathroom, right after cleaning. Can we dry the floors somehow? While painstaking, going through the 5 Whys can uncover a level of detail that gets to the bottom of these challenges. And, often, it’s the small changes that can mitigate the greater risk.
Consider the humble grab bar. They’ve been around for years, pretty much unchanged. In a behavioral health setting with suicide risk, the solution is often a quick bit of metal welded to the bottom of the bar — and the ‘ligature-resistant’ check box is ticked. Or they are simply removed from showers and toilet areas. These efforts may appear to solve the problem, but there is more to this than meets the eye. They can, in fact, create two other potential concerns:
1. By closing off the grab bar, we’ve created a place for water to pool and harbor bacteria, increasing HAI risk.
For something as simple as grab bars for behavioral health, there are many options, each with their own tradeoffs: cost vs drainage; drainage vs ligature resistance; cleanability vs manufacturability; universal fit vs grasp-ability; cost vs durability; simplicity vs vandal resistance; ad infinitum. An overarching look at patient safety may deem these details trivial and innocuous. But, ignore them and the big picture is incomplete. When viewed in detail, they may seem negligible. It’s when you consider them as contributing factors in a larger system of ‘whys’ and ‘what-ifs’ that a clear picture begins to emerge.
When developing the KG270 series grab bar, we were at the drawing board constantly analyzing these unseen, interdependent factors. The result?
A. ‘Supported-Rail’ design which allows the patient to completely grasp the bar at a natural angle, while maintaining protection against ligature attachment. By working with patient ergonomics and allowing them to effectively use the grab bar, risk of fall is reduced.
B. Deep trough shape with open end to allow complete drainage and simple cleaning. Keeping the water away from the grab rail improves grip and allows a cleaning cloth to simply wipe away moisture and gunk and contribute to HAI prevention. Making it easy for environmental services will ensure it gets done.
C. Robust design and tested for abuse, ligature, and longevity. Not only must it be useful and ligature resistant, it must also withstand the abuse often meted out to the built environment in these settings.
When you’ve got a challenge on your hands, take another look…or two, or three. Get into the weeds. What you come up with might be surprisingly simple — and make a big difference.