Archive for the ‘Joint Commission’ Category
Wednesday, July 11th, 2012
I took my daughter to her pediatrician’s office for her immunizations and it never ceases to amuse me how little logic is contained within the agencies that are supposed to be protecting our health.
To prevent the spread of infection, the Medical Marijuana Advocates (a.k.a. the Joint Commission) have apparently made it a “standard” to discard or sterilize anything that comes in contact with a patient’s skin. Because if something touches one patient and then touches another, they could get deadly infections. Forget about the 600 pound inappropriate antibiotic receiving gorilla in the room. After all, inappropriate antibiotic prescriptions have nothing at all to do with cultivating or spreading resistant organisms. Actually, I don’t know what are contained in Joint Commission standards because the only way people can find out what the standards are is to purchase them at $1485 for a site license or a bargain basement $297 for an individual license. I’ll pass, thanks.
What I do know is that landfills are now full of tourniquets that touched a patient’s skin during blood draws and I have yet to see one blinded study showing how discarding tourniquets under Joint Commission “standards” has stopped the spread of pestilence in our society. Yet blood pressure cuffs that touch a much larger surface area of a patient’s skin before touching another large part of another patient’s skin get a pass. Go figure.
Then comes the bacterial nexus of death in the pediatrician’s office. No, it’s not the stethoscope. No, not the prescription pad with all the amoxicillin or azithromycin you can drink for your cough or fever. It’s something that just screams out for kids to rub their grubby hands all over it in unison to create a microcosm of shared bacterial and viral genomes that can be spread amongst unsuspecting families.
The Color Changing Finger Board!
How many kids rub their noses or pick other orifices, then touch this thing, then put their hands back in their nose or alternate orifices? Never mind. I don’t even want to know. It is like a giant JCAHO-authorized petri dish.
Maybe its a way for pediatricians’ offices to assure return visits in a couple of weeks.
Before I left, I actually touched the board. I drew a little picture of a bug in the left upper corner of the board. He was holding onto a club getting ready to beat the large alligator bug that someone gouged underneath him. How do little kids get sharp objects in the doctor’s office play room so that they can gouge pictures of alligator bugs onto the magical touch board, anyway?
After I took the picture (using my opposite hand), I went and touched a bunch of magazines. Then I touched a door handle. Then I touched some windows, a couple of desks, and a chair, too. Mwuuuuuhahahahaha.
My null hypothesis is that there will be no greater death rate in the community due to my actions.
Either that or I’m going to be quite sick in the next week or so.
That reminds me. Did I wash my hands before I started typing this post?
Wednesday, March 21st, 2012
I’ve performed conscious sedation dozens of times. Never had a problem. Not once.
For some unforeseen reason, our hospital has now decided that there are multiple additional hoops through which physicians must jump in order to be credentialed to perform conscious sedation. We have to be certified in ACLS. We have to sit through a course on conscious sedation so that we know the difference between light/moderate/heavy sedation and general anesthesia. Then we have to take a test on the medications we prescribe to make sure that we know that the medications may … make patients drowsy. There are several “pre-procedure” forms that we have to complete to determine how difficult a patient may be to intubate … if intubation is needed. And, while the patients are in their sedated state, there is a six page form that the physicians must complete – in addition to another several page form that the nurses must complete. Looking through all the additional proposed paperwork, I’m not really sure how there will be time to do the procedures when all of the paperwork is required to be filled out and medical care will obviously just get in the way.
Yup. Conscious sedation just became a whole lot “safer.”
But I just don’t think that the paperwork is appropriate, and I think the overwhelming focus on paperwork is bad medicine. Because of that, I withdrew my privileges for performing conscious sedation. I’m not the only doctor who has done so, either.
Now, if patients need conscious sedation performed while I’m working, the hospital has decided that I am no longer competent to perform the procedure.
From this point forward, patients who need conscious sedation in the emergency department will get an anesthesiology consult and the anesthesiologist can
deal with the hassles if every last one of the multitude of checkboxes hasn’t been completed make sure that the conscious sedation is performed properly. That will cost substantially more money be safer.
And from this point forward, if the anesthesiologist is busy in the operating room (which is likely during the day) or is gone for the day (which is likely at night) and can’t come to administer the same medications that emergency physicians administer all the time, the patient will have to be admitted and the procedure will need to be performed in the operating room. That will be even more
expensive and time consuming safe.
Patients with dislocations or other painful conditions who need procedures performed will have to wait. I’m competent to give them IV pain medications (we’ll see how long that lasts), but just not IV sedation. Patients who need IV sedation will need to speak to the anesthesia specialists. I’d like to help and I’m able to help, but I’m just no longer certified to help. Everyone is just looking out for your safety.
Now the Medical Marijuana Advocates (nee “the Joint Commission”) has further justified its existence because it can now REVIEW the stack of charting required for every patient that has received conscious sedation and
threaten the hospital with decredentialing if every last check box on every last form hasn’t been completed correctly make sure that things are safe. It might even be able to create a booklet to describe how to pass inspection for said paperwork which will cost $595 per year be made available to hospitals. Hospitals will then be able to hire advanced consultants to look over all the paperwork and make sure it is complete before JCAHO comes to visit.
But patients will be “safer” …
at least on paper.
Isn’t that all that matters?
Wednesday, February 16th, 2011
I had a whole story ready to post about another very sick child that we treated, but decided to leave a more general issue instead.
When there are critically ill patients, the staff has to think quickly and act quickly. Interruptions are counterproductive to our job during those times. Think about trying to concentrate on something – whether it be driving and trying to find a street address, talking on the phone, or trying to figure out a crossword puzzle – and being interrupted by your kids. The interruptions knock you off track from the task at hand.
There was a 6 month old who was critically ill in our department. With children, tasks such as starting IVs and intubating them are more difficult, and you also need to check the dosages of medications that they’re being given since pretty much all medications for children are weight-based. All the medical providers really need to focus.
So how do we manage a situation in which the parents are interrupting the care of their infant child?
I understand that seeing all of these things happen to your child is a scary experience. I understand that parents want to be there with their sick children. I’m a parent. I’ve seen it with my children.
Should the physician trying to save a child’s life stop what he or she is doing to explain to the parents what is happening – which may affect the survival of the child – or should the physician get done what needs to be done and talk to the parents later?
Some parents are very good about staying out of the way and just watching what is happening. But some parents will push you out of the way to stand next to the child, holding the child’s arm and caressing the child’s head when you really need access to the arm and the head.
If the family’s expectations are not met while you’re trying to save the child’s life – whether it is because you didn’t answer questions to the family’s satisfaction, whether you asked them to do something they didn’t want to do, or whether you said something to the staff that the family took the wrong way, then you may find yourself at the end of a complaint to hospital administration.
If you everything necessary to meet the family’s expectations, but doing so causes delays in caring for the child and the child suffers a bad outcome, then you may find yourself at the end of a malpractice lawsuit.
I know that some people will suggest “meeting in the middle.” That is fine and usually works well in most situations.
However, there are times when “meeting in the middle” doesn’t work, and those times may cost a child his or her life.
Should we excuse all family members from the room during critical care moments to decrease the likelihood of medical errors related to interruptions?
If we’re talking about “patient safety issues,” situations like this occur a lot more frequently than some of the other things that JCAHO tries to regulate.
Does JCAHO need to regulate family visitation?
Wednesday, February 9th, 2011
Remember that statistic from the 1999 Institute of Medicine report that trial lawyers like to throw in everyone’s face about how “up to 98,000 people in the US die each year due to medical mistakes”? It’s like TWO 737 jetliners crashing every day … and we’re doing nothing about it.
So today a news story was sent to my inbox that included Saudi Arabian Ministry of Health statistics on medical malpractice. The report shows that there were 1,356 cases of malpractice in Saudi Arabia in 2009 and that “129 people died from medical mistakes in 2009.” Of course, the 129 number seemed quite low to me given the 98,000 number that is constantly cited in the press. Maybe Saudi Arabia’s population is just smaller than I thought.
Nope. Saudi Arabia has a population of roughly 26 million – about 1/12 of the 310 million people in the United States. Multiply those 129 Saudi Arabian deaths by 12 and the population adjusted death rate from medical mistakes in Saudi Arabia is 1,548 — versus 98,000 for the United States.
Look at it another way. Divide 98,000 deaths from medical mistakes in the United States by a population of 310 million and you get about 316 deaths per million population in the United States due to medical mistakes.
Divide 129 deaths from medical mistakes in Saudi Arabia by 26 million population and you get about 5 deaths per million population in Saudia Arabia from medical mistakes.
316 deaths per million in the US versus 5 deaths per million in Saudi Arabia.
Is medical care in the United States that much worse than in Saudi Arabia — even without the benefit of safety agencies such as the Joint Commission and HospitalCompare.gov?
Or do unrealistic requirements from “safety” organizations such as the Joint Commission and “quality measures” from our government actually cause more deaths from medical mistakes?
Or are the Institute of Medicine’s numbers so far off that they shouldn’t be believed?
I did a little more searching.
This parliamentary paper from the United Kingdom pegs deaths due to medical “incidents” at about 3,500 per year in England. In a country of 52 million people, that averages out to about 67 deaths per million population – still about one fifth of the alleged United States numbers.
Then I found a Canadian study showing that the range of deaths from “medical misadventures” in various industrialized countries ranges from 1 per million population to 10 per million population. The US is in the middle of the pack at about 6 deaths per million population per year – which equates to about 1,860 deaths per year from “medical misadventures” in the United States.
1,860 deaths versus 98,000 deaths
Why are the numbers in that IOM paper such outliers?
And why do the trial attorneys keep citing it as gospel?
Saturday, January 8th, 2011
There are a lot of bonehead stories about the Joint Commission in the news lately. I just had to post this one.
CMS and JCAHO are now investigating Lehigh Valley Hospital in Pennsylvania for using stun guns on unruly patients.
In one instance, a patient was using an IV pole as a pugil stick before security guards used a TASER to put him to the ground. In two other instances, patients were beating on security guards when they were “tazed.”
Protecting yourself is apparently a “violation of state and federal health rules.” As a result of the stun gun incidents, the hospital was ordered to retrain certain staffers in responding to behavioral emergencies. Security and emergency department staff had to be trained in comprehensive crisis management. The hospitals also had to establish a task force to track “incidents” and ensure that staffers had used the “least restrictive measures” when restraining a patient.
When are you guys going to learn? When a patient is choking the life out of you, you HAVE to offer them milk and cookies then tell them to go to a secluded room before you try to defend yourself. Those are the rules. If they have their hands around your windpipe and you can’t breathe, then just point emphatically to the secluded area.
Wouldn’t it be … interesting … to watch an “unruly patient” attack a CMS investigator and then watch hospital staff utilize mandatory CMS protocols to intervene?
Sir. SIR! How about you stop disarticulating that man’s elbow. Really now. Would you like some juice instead? We have apple, grape, and cranberry. Maybe some nice Saltines and peanut butter? No? Hey! Now if you don’t stop poking your fingers in that man’s eyes, we’re going to have to bring you to a secluded area. I’m not kidding, Mister. And you, Mr. Investigator – stop trying to fend off his attack with your clipboard. Don’t you know the patient could injure his knuckles if he hits that clipboard instead of your face? OK, Mister. I see the Investigator’s blood dripping all over the place. Someone might slip and get hurt. You are officially creating a patient safety hazard. NOW you’re getting CITED! SECURITY!
That should calm those unruly patients.
Wednesday, December 29th, 2010
“Severe pain can trigger suicide in hospital ERs” the headline reads. If they’re still calling it an “ER” you already know they’re clueless.
The article at the National Library of Medicine cites a new “Sentinel Event Alert” from the Joint Commission (.pdf download) urging emergency departments to be on the lookout for patients who may commit suicide in the Emergency Department.
Since 1995, there have been 827 reports of patient suicides in the United States. Of those, about 14% are in non-behavioral health units, making a total of about 116 non-psychiatric inpatient suicides in 15 years. That’s about 8 inpatient suicides per year out of 198 million inpatient days per year (644 inpatient days per 1000 population in US x 307 million US population) for a total chance of an inpatient committing suicide on any given day of … 1 in 24.75 million. Now I admit that the numbers may be off by one in a couple million or so because reporting suicides is voluntary for hospitals, so not all suicides get reported.
The Joint Commission also breaks down the number of suicides reported in the emergency department since 2005 — 8% of 827 reports or about 66 patients. In 15 years in all the emergency department in the country, 66 people killed themselves. That adds up to about 4 patients per year. Let’s round up to 5 patients per year who kill themselves in emergency departments. During that same time period, the number of emergency department visits per year averaged 100 million. Latest statistics show that we’re up to about 117 million emergency department patient visits per year. So the number of suicides committed per patient visit in the emergency department is about … 1 in 25 million – give or take a few million.
Now the Joint Commission’s “Sentinel Event Alert” wants hospitals to take a bunch of additional affirmative steps to make sure that even less than 1 in 25 million patients commits suicide.
Hospital staff is more likely to buy a winning lottery ticket than they are to find an inpatient who will commit suicide on any given day. Yet not only are hospital staff required to keep a close look-out for suicidal patients, but they and/or the hospitals will be held responsible for a “never event” if an inpatient actually does commit suicide.
You want an example of how people expect medicine in the United States to be “perfect”? Here it is.
I’m sure that all of the JCAHO minions are furiously typing out a counterargument that “WhiteCoat is a cold heartless person. He doesn’t care about trying to save people who might commit suicide.” Yeah, well cool your keyboards. Maybe we can ask a patient if they’re depressed or suicidal. Give them a number to follow up with a counselor. I might agree to that.
But JCAHO and our government have a page and a half long list of “recommendations” that medical providers are supposed to follow in order to prevent suicide – include “doing suicide screenings in the ER, screening all patients for depression when they’re admitted to a hospital, checking anyone deemed to be at risk for items they could use to harm themselves, and encouraging staff to call a mental health professional to evaluate patients believed to be at risk.” I uploaded the alert to EP Monthly’s site here in case JCAHO decides to take it down or the link goes dead.
Let’s say that we implement all of JCAHO’s recommendations – just in the emergency department. Not only do we need to perform all the screening, we also need to DOCUMENT that we perform all the screening because when the clipboard brigade comes knocking for an audit, you better be able to prove that you actually did the screening that they “recommend.” Conservatively, let’s say that such screening and documentation takes 10 minutes. Multiply that by 117 million patient visits. If every emergency department in the country implements JCAHO’s recommendations, emergency department staff will spend an extra 2o million hours each year looking for a needle that is in a haystack the size of Texas (which just happens to have a population of 25 million).
Those screening and documentation procedures add up to 20 million hours less patient care. That’s 20 million hours that won’t be available to treat patients waiting in the waiting rooms. Twenty million less hours to dispense medications, discharge patients, and monitor critically ill patients. More than 100 million extra pieces of paper to document adherence. And those numbers don’t even count all the extra time spent doing additional screening and documentation when the patient make it to the medical floors.
What’s the cost to the system? If we assume that emergency department nurses make $35/hour, those 20 million hours add up to $700 million per year … to screen for a problem that occurs 5 times per year. Then add in the cost of the paper and of all the supervisors who then have to go through the charts to make sure that the documentation is present (and properly completed) and the time cost throughout the country easily surpasses $1 billion. Well, if only half the hospitals in the US implement the recommendations, the cost is only a measly $500 million.
These safety recommendations were created by the government’s Patient Safety Advisory Group, a group that was chaired by an astronaut named James Bagian and co-chaired by a pharmacist named Michael Cohen. Now you have another example of what happens when non-clinicians create policy for those of us in clinical practice.
But at least patients are safer …. right?
Monday, November 15th, 2010
A friend’s hospital recently underwent a visit from the Joint Commission. I was told that JCAHO cited them for the following infractions:
- Surgilube in the patient’s rooms was expired. After expiration, I’m sure that the Surgilube turns into napalm or some other dangerous chemical so this is a valid concern.
- There was too much Surgilube in the drawers in the rooms. After all, patients could eat the Surgilube that hadn’t transmogrified into napalm and become deathly ill from Surgilube intoxication.
- Tongue blades in the drawers had no expiration date. An obvious attempt to circumvent proper patient safety. Everyone knows that the emerald ash borer eggs living in the tongue blade wood mature after a tongue blade’s expiration, eat their way out of the sterile packaging, and wreak havoc on the trees in the community. One of the trees could then fall over, harming a patient.
- There were shelves containing items that were within 18″ of the ceiling. Nothing can be within 18″ of the ceiling. No one told them why nothing could be within 18″ of the ceiling, but they were cited for having things there anyway. This, of course meant that the hospital is at risk for being decredentialed for not moving shelving, clocks, and reconstructing some door frames to make sure that the doors were not violating this important safety rule.
- Laundry in the room wasn’t covered.
- Boxes of copy paper were sitting under the printer on the floor. No paper was allowed to be sitting on the floor. The reason for this was that if the hospital flooded, the wet paper could pose a hazard to patients. Forget that the hospital sits on a relative hill, so that in order for the hospital to flood, it would probably require that a tsunami occur. Forget that the paper is in an area with no patient access. There were computers sitting on the floor which would electrocute everyone if the hospital flooded. There were garbage cans on the floor, the contents of which would turn to sewage if the hospital flooded. Oh, and there were chairs and beds and desks whose legs were touching the floors as well. But only the copy paper was cited as a violation. So the hospital administrators had the poor maintenance guy grab something from the basement on which to set the paper. Now there is an empty drawer sitting on the floor with boxes of paper perched precariously safely on top of it. Next year it will probably be a citation for not having the copy paper high enough off of the floor.
- Pump bottles of hand sanitizer were hanging on the walls by the doors. Nothing could be hanging on the walls within 12 inches of a door frame. So they had to have the maintenance guys come back up to the ED, pull the pump bottles out of the wall, and re-insert them in a wall far away from the door.
- Only after the pump bottles were moved did someone then tell them that the hand sanitizer could not be within 6 inches of any outlet – even if the outlet was GFCI (which they all are). Therefore many of the hand sanitizer bottles had to be moved a second time.
But now look at how much safer the environment is for those patients.
Wednesday, July 7th, 2010
Nurse [as she was walking out of the Dirty Utility room]: “Where’s the timer for the pregnancy tests?”
Secretary: “Oh, the lady from lab threw it out. It was expired.”
Nurse: “Wait. She came to our department and threw something in our department out? And she said that the timer expired?”
Secretary: “Yeah. She said that it could be a JCAHO violation if we were using an expired timer.”
Nurse: “It’s a f**king clock. How does a clock expire?”
Secretary: “Ask the ‘Lab Nazi.’”
We have to keep a timer in the Dirty Utility Room (which happens to be one of the many ROOMS in the emergency DEPARTMENT) so that pregnancy tests are read at precisely 3 minutes. If they are not read at 3 minutes, that could be a JCAHO violation because patient safety could suffer.
Now companies are apparently putting expiration dates on electronic equipment to assure patient safety. If electronic equipment is used past its expiration date, that could be a JCAHO violation.
They still haven’t replaced the timer in the Dirty Utility Room, so we’re officially screwed if the hospital gets inspected, but I also can’t verify whether these damn things have expiration dates on them. I need to know if anyone else out there has electronic equipment with expiration dates on it in the hospital. If so, please send me pictures. If anyone has any kind of proof about expiration of hospital electronics, I’d also appreciate it if you’d send me a copy so I can post it.
I am getting to the point that I want to become a JCAHO inspector just to mess with people’s heads. Imagine how much fun it would be to look at a chair, point at it, say it is expired, and then get 5 college graduates with advanced degrees to trip over each other in order to get rid of the chair. There’s probably some JCAHO internal message board somewhere with a Top 10 list of dumb things that surveyors got hospital admins to do.
All you medical supply companies – take note. You can increase your profits exponentially by putting an expiration date on all your equipment. Medical computers expire in 3 years. TVs used in hospitals expire in 2 years. Construction companies – chisel an expiration date in the hospitals you build. Ten years ought to do it.
Who gets to make up the rules that JCAHO follows, anyway?
Monday, June 21st, 2010
Following up on my previous post about Joint Commission micromanagement, we got word of another big “no-no” according to JCAHO’s rules.
We have now been informed that according to Joint Commission rules, in association with EPA studies, there is entirely too much drug contamination in the nation’s water supplies. Therefore, hospitals must now separate waste into multiple bins and dispose of such waste appropriately in order to avoid being fined by the EPA and sanctioned by JCAHO. And JCAHO will go through the garbage during its inspections to make sure that you are complying with the rules, too!
Regular waste goes into a blue bag. Blue bags comprise most of the waste in the hospital.
“Hazardous waste,” must be put it into a black hazard bag. Hazardous medications include epinephrine, phenylephrine (i.e. Neo-synephrine nasal spray), insulin, silvadene, nitroglycerin, prednisone, and silver nitrate sticks and others. Next time you go to the store to buy any of these products, make sure that you wear special gloves and gown. Then when you’re done purchasing them, make sure you read how hazardous they are in the product handouts and how you can only dispose of them in a black hazard bag that you must now purchase from JCAHO-licensed distributors. Oh. Sorry. These drugs are only treated as hazardous inside of hospitals. Carry on.
“Infectious waste” must go into a red bag. Infectious waste includes anything that comes into contact with bodily fluids. All you mommies who throw your kids diapers in the “regular” garbage and anyone who throws used facial tissues in the “regular” garbage is breaking JCAHO laws. Stop it now or you’ll be fined and may possibly be decredentialed.
“Dual pharmaceutical waste” means that waste is both infectious and hazardous. That must go into a purple hazard box immediately. If anything in the “hazardous waste” category comes into contact with any bodily fluid, then it fits this category. If you spray Neo-Synephrine up your nose and then blow your nose into a tissue, find a purple box immediately. The tissue may spontaneously combust.
“Non-compatible waste” must be placed in a special black bag with an orange triangle. We must then contact the pharmacy for a special waste pick up. Non compatible waste includes any asthma inhalers – due to the propellants contained in the container. In other news, the US Government is currently developing a secret group of mercenaries that will take a couple of puffs off of an asthma inhaler, spray Neo-Synephrine up their noses, cough and blow their noses into a tissue, and then throw the tissues at selected targets. Biologic warfare at its finest. Watch out Al-Qaeda. We mean business.
Controlled substances must be flushed down a toilet while another person watches and then must documented on a special sheet by the toilet. Apparently the risk of polluting our waterways pales in comparison to the threat of someone getting ahold of a couple of drops of extra morphine lying around in a syringe.
Oh yeah, and sharps have to be put in the red sharps container. BUT … if there is medication in the syringe, it must be squirted into a gauze pad and then deposited into the appropriate bin (or flushed down the toilet) as described above before the syringe is discarded.
I keep getting confused about what to do if someone pees on an asthma inhaler or what to do if a kid spits out Tylenol with codeine elixir and hits his mother’s purse.
Sitting dejectedly underneath the doctor’s desk is the lonely metal trash can with its non-JCAHO-approved clear plastic liner.
The whole colored trash can idea reminds me of my childhood.
We-he-he-he-lllll boys and girls. I’ve got a special game for you today. Here’s a pen that looks like a syringe, an asthma inhaler that was dropped in the hospital waiting room, a tissue with an unknown yellow substance on it, a shoelace, and a piece of gum chewed by someone who just immigrated to this country from Congo. Let’s play MEDICAL Bozo BUCKETS!
Stay tuned after the commercial so you can watch JCAHO teach doctors how to run their hospital medical staff.
Ho Hooo NELLLLY!
Thursday, June 17th, 2010
Remember the movie Rainman where Dustin Hoffman whipped out his red book and wrote on his “Serious Injury List” how Charlie Babbitt “squeezed and pulled and hurt my neck“? If not, you have to rent that movie and watch it. One of my favorite all time movies.
Well, the lab supervisor recently descended upon the emergency department with her notebook of Serious Offenses in hand.
“Where’s the tech named ‘Maryann’?”
“She’s not here today.”
“I need to speak to her immediately.”
“What’s the problem?”
“She wrote the results of a patient’s pregnancy test on a patient’s chart, initialed them … AND SHE’S NOT QUALIFIED TO READ PREGNANCY TESTS! The Joint Commission will see this and we’ll get cited if this isn’t corrected! Can you call her at home?”
“Um. No. Can’t one of us sign it off?”
“No. I need to know who the nurse was taking care of the patient and have the nurse document on the patient’s chart that she was aware of the findings and notified the doctor of the findings.”
[With evil smirk in eye] “We can’t do that. That would be a HIPAA violation.”
The Overseer of All Lab Discrepancies Real or Imagined then developed a perplexed look on her face and left the emergency department.
Twelve year old kids can purchase a pregnancy test and interpret the results.
Visually impaired people can purchase a pregnancy test and interpret the results.
Three year old children can tell the difference between a plus sign and a minus sign.
Yet trained professionals need to be “certified” that they can tell “plus” from “minus” on pregnancy tests under the threat of JCAHO sanctions.
Oooh. That reminds me.
I have to renew my Medical Office Building Lightswitch User Certification and my Drinking Carbonated Liquids Through A Straw accreditation. Phew. Almost forgot.