The ED of the Future


I had a run on patients with abdominal pain last night. The index finger on my right hand was developing fatigue from all the rectal exams. When I tried to find Hemoccult developer in the drawers where it is usually kept, it was all gone. Went in to the room next door, no developer in that drawer, either. What’s going on here?
Earlier in the day, the hospital administration removed all Hemoccult developer from patient rooms after JCAHO issued some dictum that Hemoccult developer should not be in patient rooms because “someone might drink it.” Of course that determination presupposes that no patient in the emergency department has a mental development more than an 8 month old child, but, technically, yes, removing a bottle of Hemoccult developer from easy patient access may make the emergency department environment just a tiny bit safer. Have there been any reports of Hemoccult developer poisoning lately? I called our poison control center and they hadn’t heard of any. But I digress.
JCAHO, like so many other similar programs, started with a good idea and then ruined itself by trying to be something it isn’t (and shouldn’t be). Safety is one thing. But this nit-picking micromanagement is becoming uber-micromanagement and is ruining the practice of medicine.
But I do have a concern with improving safety in the emergency department. For that reason, I have created a list of other items that should probably be removed to make hospitals a safer environment:

  • If patients might drink the developer, they may eat the Surgilube, so get that out of the rooms, too. Who knows what would happen, but it couldn’t be very safe.
  • Gauze sponges could be ingested and cause an intestinal blockage. Gone.
  • Patients might turn on the cardioverter, could put the paddles on their own chest and shock themselves into asystole. Even if they can’t figure out how to turn it on, they could grab the wires to the paddles and swing the paddles around over their head like a modern-day Hopalong Cassidy, klonking an unsuspecting staff member who walks into the room. Store those things under lock and key in the basement where no one can get hurt.
  • People might eat soap, too. Even worse, soap could be dripped on the floor and cause a slipping hazard. Get all of the soap out of patient rooms unless it has been certified as “non-toxic” AND “non-slip” by JCAHO.
  • Pillows could smother someone if they are held over the face and direct pressure is applied, so all pillows must be removed.
  • Sheets and blankets could be tied into a noose and wrapped around someone’s neck, so having sheets and blankets in the rooms is a hazard, as well.
  • And beds are a falling hazard. We can’t keep the railings up because we can’t “restrain” patients’ movement, but if we did, patients could climb over the railings, fall on the floor, and break their necks. In addition, patients could slip on the soap they spray on the floor, fall and hit their head on the edge of a bed, sustaining a laceration for which CMS will not reimburse hospitals. Therefore beds are a dangerous item and should be removed from patient rooms as soon as possible.
  • Actually, water could be ingested in such quantities that it causes hyponatremia and brain herniation (this just reminded me of an amusing story – future post in the making). It could also be sprayed in the eyes of hospital staff, temporarily blinding them, causing them not to see soap on the floor, slip, and fall and hit their head on the beds. Remove all sinks and faucets from patient rooms IMMEDIATELY!
  • Oh, and when patients register, they might be tempted to poke their eyes out with pens or give themselves paper cuts over their radial arteries with the admission papers they have to sign, so we really have to keep pens and paper away from patients at any point during their hospitalization.

Based on the the thoughtful and insightful considerations from our benefactor JCAHO, I have come up with a rendering of what the ED patient room of the future will look like:


No bed. No drawers. No sink. No nothing. Of course, this rendering should probably have rubber floors and walls because healthcare workers might get injured banging their heads on walls and floors dealing with all the micromanagement. But wait, could rubber cause an allergic reaction in some patients? Maybe everything could be coated in thick layers of impact-absorbing cotton. But what if patients haven’t cut their fingernails and use their talons to dig the cotton out of the walls…? Is this safe?

Maybe I’ll just end it all and drink some Hemoccult developer.


  1. This is the funniest post I’ve read in a very long time. Bravo for clearly demonstrating the insanity of micromanagement! I feel your pain… At my hospital there was no way to bill for a DRE/hemoccult test unless the card was read by the lab. So we docs actually had to tube all the cards to the lab to have them document the readings so the hospital could bill for the tests. After 10 years of medical training, and 35+ years of life experience in observing colors, I had to have a lab tech confirm whether or not a piece of paper is blue. Ah… the system.

  2. We had to take all the peroxide and betadine out of our unlocked cabinets because people “might drink it.” Makes doing blood cultures really great as you search around for the six chlorhexadine prep swabs they hide in super secret areas. The docs finally wised up and, in a box labeled “airway supplies” that they keep behind the desk, they put bottles of rubbing alcohol, peroxide, and betadine. I sneak back there and use it all the time, making very sure not to drink any.

  3. Your suggestions are good, but perhaps it would be better to just post a security guard outside of every room given all the hazards?

    BTW, I see your room has a window; that could certainly cause someone to look through it, blinding them temporarily by looking at the sun, and falling. Of course, the glass itself is dangerous as well! If an opera singer decided to practice opera in the hall, she could hit a high note, causing the window to break, leaving dangerous shards of glass EVERYWHERE.

  4. Thanks for the laugh.

    We’re not even allowed to have the hemoccult cards in the NICU any more. We can’t have 60cc syringes on our supply carosel, because the druggies might want them, but we CAN have TB syringes in drawers at the bedside. Go figure.

    We’re also not allowed to have saline flush syringes at the bedside, because they are labeled “for use by or on the order of a physician” so they MUST be dangerous.

    Fortunately, the only time anyone pays any attention to that last bit of nonsense is when we get the code for “the micromanagers are in the house” over our computerized message system.

  5. Nurse K-

    You forgot to mention the flourescent light in the room with its glass bulb and 60 Hz alternating current electricity that’s sure to pose a hazard of fibrillation to the most unsuspecting sole… better take that out, too.

    Ah, the dark… now we’re getting somewhere…

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  7. Very funny. Although I do have to say, my husband is a fiddler. He likes to play with all the equipment. I’ve already warned him not to touch anything in L&D lest we get kicked out.


  8. “We had to take all the peroxide and betadine out of our unlocked cabinets because people “might drink it.” ”
    Actually, I went down to the ED to admit an antifreeze drinker and found him sipping the hospital’s ethyl alcohol (If I recall correctly). It was brilliant.
    Also, we had a guy that would drink the hand wash alcohol from the wall dispensers, so take those out too.

  9. Come to think of it, we had a girl smear her own feces all over the walls and floors. Someone could slip in that…better remove the floor.

  10. I can only imagine your fustration of MICROMANAGMENT!!! However everything that has been said is from your view. So here is the other side….
    Why is that a surgeon can’t read FLAMMABLE on a skin prep, or the nurse who had no idea how to apply the flammable skin prep, or the surgeon who heard over and over a popping sound and never looked at the patient!!!! Think they need MICROMANAMENT??? Just pray your never the sedated patient in the OR being set on fire!!! The worse part is all the education doctors, nurses and adminstrators many still have no idea how to put out a surgical fire. Maybe Micromanagment should be placed in the OR!!!! in the form of a video camera!!! That would be scary.

  11. Rules of the bureaucracy
    1. Bureaucracies exist to perpetuate themselves.
    2. All Bureaucracies begin with a valuable intent but within a decade they reduce that purpose to an absurdity.
    3. Bureaucratic decisions are not to be evaluated empirically but must be regarded as revelations.

  12. You forgot to mention the flourescent light in the room…

    Well certainly, in addition to what Dr. Wes said, a fun-lovin’ patient could mistake it for a light saber and you for Darth Vader and voila, it’s a fight to the death, winner take all. It’s certainly plausible if not probable, and I’m glad we have regulators to watch all this stuff.

    Don’t even get me started on my visions of everything that can go wrong with the handle of those mops housekeeping carelessly leaves lying around. Can anyone say “foreign body”? Between mop handles and the long fluorescent bulbs, hospital will need to train more colorectal surgeons like yesterday.

  13. Absolutely hysterical!

    We have to lock all our drugs up in the anesthesia cart, along with our airway supplies. Imagine bringing an emergency case into the OR (happens all the time) and having to fumble around looking for what you need FAST.

    I say we put JCAHO into that room, open the window, and hope they jump. Self-fulfilling prophecy.

  14. As an opera singer, I resent strongly the insinuation that we practice in unsafe conditions. From our very first voice lesson, we are given constant lectures on how to respect the hazards of the profession, including the highly important “singing in hallways that might possibly have glass windows in rooms adjacent.”

    Besides, in every opera singer’s capacious music bag is a hazard kit that contains (among other things) a broom and dustpan, and a roll of yellow hazard tape.

    You won’t get glass shards from me!

    –thanks for a fun post/discussion

  15. BTW, JCAHO wants to be called “The Joint Commission” now. My pet peeve is their obsession with the security of patient information that extends to requiring passwords on electronic medical records systems that have three types of characters (alpha, numeric and “special”), can’t be reused because the system keeps track of the last ten, and must be changed every 90 days. It is frustrating to the physicians, especially, to have to remember their PWs so they can comply with documentation regulations, and if they practice or rotate to different hospitals in the area, they have to remember different PWs. We are told not to write these down, but who can remember? It’s counterproductive. Given that people DO write these PWs down somewhere, the whole system is less secure than before. It’s that syndrome of not knowing when to stop: if some security measures are good, then more and increasingly complex security measures have to be better. To apply Dr. WhiteCoat’s logic, let’s make the electronic records system accessible to no one–instant and ultimate security.

  16. LMAO! Too funny!

    They recently started keeping all housekeeping supplies “locked” during the night.
    Of course, there are no house keepers on duty on the floor during night shift.

    So now, when a patient soils the bed and the linen needs to be changed – guess what? You can’t find spare “dirty linen” bags. Or you can’t find sani-wipes. Or floor disinfectant.

    I think management has this absurd idea that nobody wets their beds at night.
    I still can’t figure out why the blessed things are under lock and key….

  17. Bureaucracy gone wild, indeed! I was LMAO reading this, given that we were HIPAA’ed and JCAHO’ed to death during my medical records curriculum…just more evidence that the whole system needs a complete overhaul!

  18. ISMP, not the Joint Commission:

    These solutions should never be left in areas where they could be confused with eye drops (e.g., bedside tables, medicine carts, patient bathrooms). To ensure safe storage, you may want to secure the bottles (using string around the neck) to a fixed object where stool specimens are tested.

  19. If I understand my navy friends correctly, only naval aviators can become carrier captains, and only former deep water ship captains can become commodore of a naval base; our problem now, is the people woh have been put in charge of our hospitals by “the money” know nothing about making care, and lots about finance and marketing. That won’t change until there is no more money to divert from care to pockets, when they will all abandon ship to sell toothpaste or hamburgers….

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