JCAHO Issues Alert on Emergency Electrical Power System Failures

OAKBROOK TERRACE, Ill. – The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued a Sentinel Event Alert that urges health care organizations to pay special attention to how emergency power systems can fail and recommends specific steps to keep patients safe in the event of a disaster or other major event that knocks out the organization’s electrical power supply.

Reports from the 2001 floods in Houston, the 2003 blackout in the Northeast, and hurricanes that have hammered the Southeast over the past two years show how severely clinical operations can be affected in health care organizations that lose their electrical power. The Sentinel Event Alert brings the reality of these risks to the attention of the nation’s health care organizations, and offers practical solutions to avoiding adverse patient care events in the event of electrical power failure.

“Health care facilities are highly dependent upon reliable electrical power; but recent experiences show that emergency power systems are not always sufficient during a major catastrophe,” says Dennis S. O’Leary, M.D., president, Joint Commission.  “These organizations must recognize the potential fragility of external electrical power sources and their own emergency generator systems, and develop appropriate contingency plans that can be activated when needed.”

According to the Alert, compliance with minimum National Fire Protection Association (NFPA) codes is not enough to assure the safety of patients and their care during an emergency situation. For example, many health care organizations did not have sufficient power to cool or ventilate facilities in the sweltering aftermath of Hurricane Katrina. Further, patient evacuations were delayed because of the insufficiency or unavailability of electricity-dependent elevators to transport patients.

To reduce risks to patients created by power failures, the Joint Commission’s Sentinel Event Alert recommends that health care organizations take the following specific steps:

  • Match the critical equipment and systems needed in an extended emergency against the equipment and systems actually on the emergency power system
  • Inventory emergency power systems and the loads they serve
  • Provide training for, and test, those who operate and maintain the emergency power supply system
  • Ensure that generator fuel is available and usable
  • Assure that the organization management and clinical leaders know how long emergency power will be available and what locations within the facility will and will not have emergency power in the event of an electrical outage
  • Establish contingency plans for doctors and other caregivers to follow during losses of electrical power

In addition to the Alert, the Joint Commission is adding a new requirement in 2007 that organizations test emergency generators at least once every 36 months for a minimum of four continuous hours. Facilities already must test their generators 12 times a year for 30 minutes. If a test fails, the organization must immediately implement stop-gap measures until a permanent fix can be put into place.

The warning about risks associated with emergency electrical power system failures is the latest in a continuing series of Sentinel Event Alerts issued by the Joint Commission. Much of the information and guidance provided in these Alerts is drawn from the Joint Commission’s Sentinel Event Database, one of the nation’s most comprehensive voluntary reporting systems for serious adverse events in health care.  The database includes detailed information about both adverse events and their underlying causes. Previous Alerts have addressed wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found on the Joint Commission Web site, www.jointcommission.org.

For more resources on addressing electrical power failures, visit the Joint Commission International Center for Patient Safety’s free, online database of practices and interventions to prevent adverse events at www.jcipatientsafety.org.


JCAHO Sept. 6, 2006 release

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