Aft Task 1

Nightingale Hospital complying with Joint Commission’s is not occurring. The Universal Protocols (UP) met on some months and not on others. The Time-Out Hospital Wide UP looks like hospital was increase in compliance over the year and reached the one hundred percent make until December. This protocol should be preform at every surgery or minor procedure (where necessary) according to hospital policy in which involves laterality. The National Patient Safety Goal Data (NPSG) for communication in Hospital Wide Compliance of Reporting Critical Results within sixty minutes met one hundred percent, zero

There are two prohibited abbreviations that are tracked, “cc” and “qd”, as they are the most common. Throughout the year there has not been consistent improvement in the area. The trending data shows some improvement in parts of the year and then some months, April and September, to have increased spikes of use of prohibited abbreviations. During the PPR it was noted that the following departments were non-compliant concerning using prohibited abbreviations: 3E, 4E, ICU, and Telemetry. The

Nightingale Community Hospital identified a recent sentinel event involving the ambulatory surgical center. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). A three year old female presented to the hospital on September 14th for a planned outpatient procedure. The child was accompanied by her mother. The mother registered the patient with the registrar prior to the procedure. The patient and her mother went to the pre-operative area to complete the informed consent and the necessary physical assessment. The pre-operative nurse obtained the necessary contact

This sentinel event involves child abduction from the surgical unit of Nightingale Community Hospital on Thursday, September 14, 2014 at approximately 1230hrs. The patient, a three-year old female, arrived accompanied by her mother, for an outpatient surgical procedure at 0800hrs and proceeded to registration where all currently required documentation was completed and signed by the mother; this included the authorization forms for the surgery. After registration, the patient and her

A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began

* Personnel Issues: One of the key barriers to effective interaction for the pre-op nurses is that they are not getting any information from the registrar or the surgeon related to the patients unique circumstances. There is not a communication process in place for the pre-op nurse to actively communicate with the surgeon or his office regarding a patient’s care during their day of surgery. An additional factor in this situation was the pre-op nurse documented the mother’s contact information in her notepad, but not on the

The tracer was performed as part of a process improvement to assess compliance with The Joint Commission standards (The Joint Commission, 2015). In this process, a random patient chart was chosen and the process followed from admission to discharge including any directly related follow-up or readmission.

The purpose of this report is to summarize, analyze and evaluate the compliance status of Nightingale Hospital to Joint Commission requirements. This report will focus on medication management, specifically anticoagulation therapy and the patient and staff education associated with it. In an effort to maintain the highest quality of care for our patients, we must continue to work towards a reduction in adverse anticoagulation related events. This will involve proper pre-discharge

The high cost of healthcare continues to rise and many in the United States are optimistic for health information technology to reduce and improve our current situation. Health IT encompasses a broad array of new technologies designed to manage and share health-related information. When properly implemented, these systems can help coordinate patient care, reduce medical errors, and improve administrative efficiency. Therefore, implementing a Regional Health Information Organization (RHIO) will help the National Health Information Network (NHIN) achieve their goals in improving quality of care for the citizens of the United States. Thus, in order for the health IT to deliver on its promise, several obstacles must be overcome.

Nightingale Community Hospital is a 180-bed acute care hospital that is a not-for profit entity. The hospital is community based and provides leadership in quality health services in which they provide. Their vision is to be the hospital that people choose, the place employees, physicians and volunteers want to work and a hospital of choice for the community. They are committed to providing a healing environment to their patients with a compassionate commitment to healthcare excellence.

In preparation of a review from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Nightingale Community Hospital will focus on improving its communication process in the operating room. The purpose of communication in the healthcare setting is to disseminate information in such a way as to create shared understanding about the patient and about what needs to be done for a positive outcome. (synergia.com) A patient is at his most vulnerable state during procedures that require sedation or anesthesia. The patient is releasing his decision making ability and safety into the control and care of the healthcare team. Therefore, effective communication on behalf of the patient is

As our Joint Commission audit approaches, Nightingale Community Hospital has conducted a tracer patient survey to assess our compliance. The tracer methodology tracks a selected patient's care from admission to discharge, allowing us to evaluate our systems of providing care and to ensure that we are meeting the Joint Commissions standards of providing safe, quality healthcare.

November of 2004, medical abbreviations supported the "Do Not Use" list. They created a website and in approximately four weeks, Joint Commission received tons and tons of responds and comments. And more than 80% supported the "do not use "list. Reason why so many use it is because some pharmacists in the forms misunderstand some of the stuff that is written. In 2001, The Joint Commission a Sentinel Event Alert on the subject of medical abbreviations. They are also the ones that in 2004, The Joint Commission created its "do not use" list.

Central Hospital in Tempe, Arizona decided to implement a computerized Medication Administration Record (MAR) into one of their small locations before rolling it out to the entire organization. Art Baxter, the Chief Information Officer in charge of Medical Information Systems (MIS) at Central Hospital assigned Kate Cohen, a programmer and analyst, as the Project Manager. Kate formed a project team but failed to include representatives from departments that were going to use the system. Unfortunately, the key stake holder/users did not have a seat at the table. Even though the

The variation in information needs across any healthcare provider organization forces healthcare information technologies (HIT) platforms, systems, processes and procedures to align its design to support the unique information needs of each department and role. The greater this alignment of HIT systems and technologies to specific administrator, doctor, nurse and lab technician roles, the higher the level of overall systems performance and results attained (Agrawal, Grandison, Johnson, Kiernan, 2007). Just as an enterprise has strategic information needs that help to define the future direction of the business, healthcare provider organizations also have a comparable set of strategic information needs. The administrative roles in healthcare providers need to have a consolidated view of the organization from a cost, quality management, service level, patient recovery rate, patient satisfaction and profitability standpoint as well (Middleton, 2005). All of these factors are often gathered together in a dashboard that administrators often rely on to manage the core areas of their healthcare business (Leung, 2012). Administrator's information needs are also longer term in nature and more oriented towards the development of strategic initiatives that will last several years, requiring