DNV GL Healthcare Revises Interpretive Guidance for Patient Rights Standard PR.2

PUBLISHED: Jan 7, 2019
Relevant to: Hospitals

DNV GL Healthcare recently updated their NIAHO Hospital Accreditation Requirements, effective January 21, 2019. As a part of these revisions, changes have been made to NIAHO’s interpretive guidance for Patient Rights standard PR.2. The changes are intended to provide additional clarification regarding care in a safe setting specific to ligature risk.

Specific guidance includes:

  • Not all patients with psychiatric conditions or a history of a psychiatric condition are cared for in psychiatric hospitals or psychiatric units of acute care hospitals.
  • Non-psychiatric settings of all hospitals where patients with psychiatric conditions may be cared for must identify patients at risk for intentional harm to self or others and mitigate environmental safety risks.
  • Psychiatric patients requiring medical care in a non-psychiatric setting (medical inpatient units, ED, ICU, etc.) must be protected when demonstrating suicidal ideation or harm to others. Protection can include:
  • 1:1 monitoring with continuous visual observation
  • Removal of sharp objects from the room/area
  • Removal of equipment that can be used as a weapon
  • While all risks cannot be eliminated, hospitals are expected to demonstrate how they identify patients at risk of self -harm or harm to others and steps they are taking to minimize those risks in accordance with nationally recognized standards and guidelines.
  • Hospitals should use a patient risk assessment tool appropriate to their patient population, care setting and staff competency to identify patients at risk for self-harm.
  • Hospitals should implement an environmental risk assessment strategy that is appropriate to their patient population, care setting and staff competency - strategies may not be the same in all hospitals

Included with today’s notice are example policies related to the identification, assessment and protection of patients at risk for self-harm. Also included is a link to the revised NIAHO hospital standards.

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