AL 14-07 Installation and Relocation Checklist for Ceiling Mounted Lifts.pdf

AL14-07

AL14-07 July 28, 2014

This Patient Safety Alert AL14-07 replaces and supersedes Patient Safety Alert AL10-07 issued on March 22, 2010

Item:

Issues continue to occur due to improper ceiling mounted patient lift installation, maintenance and inspection

Specific Incidents: Patient Safety Alert AL10-07, issued on March 22, 2010, instructed VA facilities to complete an after installation checklist for ceiling mounted patient lifts on all newly installed, ceiling mounted patient lift systems (see Reference 1). Since the release of AL10-07, VA medical centers have continued to report adverse events and close calls involving ceiling mounted patient lifts (see below). While no injuries have occurred, patients and staff can be seriously harmed when lifts collapse or fall. These reports have prompted the review of installation and maintenance procedures for ceiling mounted patient lift systems, which has resulted in the issuance of this Patient Safety Alert.

A lift collapsed while a patient was being transferred from a wheelchair to a bed. Investigation revealed that a set screw, which secures the transverse rail to the rail trolley, had not been properly tightened during installation and the transverse rail was missing the proper end stops.

A lift unit fell off the rail. It was determined that an end stop was missing from the system.

A lift unit fell off the rail after preventive maintenance procedures were performed on the lift. It was established that the docking gate for the lift unit had not been secured.

A lift bracket broke loose while lifting a patient from a bed to a wheelchair. It was revealed that a snap clip (“C”-clip) came off the end of a pin, allowing the strap that connects the lift bracket to the lift unit to detach.

A lift unit fell off the rail when it was moved through a circular gate (transition gate). Investigation revealed that a safety block, which prevents the lift unit from exiting the open end of the track/rail, was not installed properly.

General Information: Due to the incidents described above, Patient Safety Alert AL10-07 is being replaced with this Patient Safety Alert, AL14-07. This replacement Patient Safety Alert notifies the field of updated actions and ensures parties responsible for ceiling mounted patient lifts are aware of the requirements for initial installations, maintenance and recurring inspections of ceiling mounted patient lifts.

Actions: 1. By Close of Business (COB) July 30, 2014, the Medical Center Director (or designee) shall ensure that the Nurse Executive, Safe Patient Handling Coordinator, Chief of Facilities Management, and Chief of Biomedical Engineering are made aware of this Patient Safety Alert AL14-07.

2. By COB September 5, 2014, Manager of the service(s) responsible for maintaining ceiling mounted patient lifts (or designee) shall determine if any ceiling mounted patient lift systems (of any brand or manufacturer) have been installed in the facility, including Community Based Outpatient Clinics (CBOCs), and ensure the following are completed:

a. For ceiling mounted patient lifts within your facilities, verify that the facility has an “After Installation Checklist for Ceiling Mounted Patient Lifts” as required by Patient Safety Alert A10-07 (see Reference 1) on file.

i. If so, continue to Action 2b.

ii. If not, complete an “Installation or Relocation Checklist for Ceiling Mounted Patient Lifts” (see Additional Information) on the lift system(s) in question.

b. Put a process in place to ensure inspection of ceiling mounted patient lifts upon installation or relocation, prior to permitting the equipment to be used for patient movement.

The process must include, at minimum, the completion of the “Installation or Relocation Checklist for Ceiling Mounted Patient Lifts” (see Additional Information).

NOTE: The “Installation or Relocation Checklist for Ceiling Mounted Patient Lifts” includes minimum requirements for inspection of ceiling mounted patient lifts; this list shall be used in addition to manufacturer provided checklists prior to permitting the equipment to be used for patient movement.

3. By COB September 12, 2014, Manager of the service(s) responsible for maintaining ceiling mounted patient lifts (or designee) shall put a process in place to ensure that the items listed in the “Corrective and Preventive Maintenance Checklist for Ceiling Mounted Patient Lifts” (see Additional Information) are inspected and verified during corrective and preventive maintenance, prior to permitting equipment to be used for patient movement.

For preventive maintenance (PM) procedures, the entire “Corrective and Preventive Maintenance Checklist for Ceiling Mounted Patient Lifts” shall be completed.

For corrective maintenance (CM) procedures, the entire

Ceiling Mounted Patient Lifts” shall be completed after:

‐ Modifications to or replacement of the lift unit ‐ Replacement of the lift strap ‐ Modifications to the track/rail structure ‐ Other major corrective maintenance procedures that may not be identified above

For minor corrective maintenance procedures that do not fall into the above categories, the Manager of the service responsible for maintaining ceiling mounted patient lifts (or designee) shall determine the relevant sections of the

Ceiling Mounted Patient Lifts” to be completed.

NOTE: The “Corrective and Preventive Maintenance Checklist for Ceiling Mounted Patient Lifts” includes minimum requirements for inspection of ceiling mounted patient lifts; this list shall be used in addition to manufacturer provided checklists prior to permitting the equipment to be used for patient movement.

4. By COB September 19, 2014, the Patient Safety Manager must document on the VHA Alerts and Recalls Web site (http://vaww.recalls.ncps.med.va.gov/WebRecalls/Recalls.html) that medical center leadership has reviewed and implemented these actions. Facilities that do not have ceiling mounted patient lift systems may mark this Alert as ‘not applicable’, including their http://vaww.recalls.ncps.med.va.gov/WebRecalls/Recalls.html justification.

NOTE: When closing out this Patient Safety Alert on the VHA Alerts and Recalls Web site and entering in the “estimated number of patients affected per month” field, it is recommended that sites enter the average number of patients that use ceiling mounted patient lift systems per month within their facility.

Additional Information:

1) Installation or Relocation Checklist for Ceiling Mounted Patient Lifts

2) Corrective and Preventive Maintenance Checklist for Ceiling Mounted Patient Lifts

3) Hazard Summary - Common Failure Modes of Overhead Ceiling Lifts

4) Ceiling Lift Hazards and Mitigations Presentation

Source: Patient Safety Reports submitted to NCPS from VA Medical Centers

References:

1) Patient Safety Alert AL10-07, Ceiling mounted patient lift installations, March 22, 2010 http://vaww.ncps.med.va.gov/Guidelines/alerts/Docs/AL10- 07CeilingMountedLift.pdf NOTE: This Alert has been retired, but is provided here as a reference for Action 2.

2) VA Handbook H-18-8 Seismic Design Requirements, August 2013 http://www.cfm.va.gov/til/etc/seismic.pdf

3) VA Directive 7512 Seismic Safety of VA Buildings, October 12, http://www.va.gov/vapubs/viewPublication.asp?Pub_ID=581&FT ype=2

4) VA Master Design Specification 13.05.041 Seismic Restraint Requirements for Non-Structural Components, January 1, 2014 http://www.cfm.va.gov/TIL/spec/130541.doc

Contacts: Shelly Crisler, Center for Engineering, Occupational Safety and

Health (CEOSH), (314) 894-6100 x 66060, Shelly.Crisler@va.gov

Kurt Finke, Director, Healthcare Technology Management Program Office, (612) 467-5778, Kurt.Finke@va.gov

Katrina Jacobs, National Center for Patient Safety (NCPS),

(734) 930-5890, VHANCPSHFEREVIEW@va.gov http://vaww.ceosh.med.va.gov/10N/10NA9-HTM/Pages/documents/AL14-07PSAChecklistforInstallationandRelocation.pdf http://vaww.ceosh.med.va.gov/10N/10NA9-HTM/Pages/documents/AL14-07PSAChecklistforInstallationandRelocation.pdf http://vaww.ceosh.med.va.gov/10N/10NA9-HTM/Pages/documents/AL14-07PSAChecklistforCMandPM.pdf http://vaww.ceosh.med.va.gov/10N/10NA9-HTM/Pages/documents/AL14-07PSAChecklistforCMandPM.pdf http://vaww.ceosh.med.va.gov/10N/10NA9-HTM/Pages/documents/CeilingLiftHazardSummary.pdf http://vaww.ceosh.med.va.gov/10N/10NA9-HTM/Pages/documents/CeilingLiftHazardSummary.pdf http://vaww.ceosh.med.va.gov/10N/10NA9-HTM/Pages/documents/CeilingLiftHazardsandMitigationsPresentation.pptx http://vaww.ncps.med.va.gov/Guidelines/alerts/Docs/AL10-07CeilingMountedLift.pdf http://vaww.ncps.med.va.gov/Guidelines/alerts/Docs/AL10-07CeilingMountedLift.pdf http://www.cfm.va.gov/til/etc/seismic.pdf http://www.va.gov/vapubs/viewPublication.asp?Pub_ID=581&FType=2 http://www.va.gov/vapubs/viewPublication.asp?Pub_ID=581&FType=2 http://www.cfm.va.gov/TIL/spec/130541.doc mailto:Shelly.Crisler@va.gov mailto:Kurt.Finke@va.gov mailto:VHANCPSHFEREVIEW@va.gov