Aft2 Task 1 Accreditation Audit

* 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

Use at least two patient identifiers when providing care. Double checking of ID bands and ID/Driver’s license of patient if possible. Using labels to mark all materials /items needed for the procedures. A two person check off procedure must be implemented. Items requiring labeling include: patient records, signed consents, and all assessments, diagnostic tests and x-rays. Also included should be any item that is needed for the procedure (blood products, devices, and equipment). Using a matching system, so that all items in the procedure area are matched to the patient. The matching system must be completed by a minimum of two staff members. These staff members should include a qualified staff member, nursing staff involved in the procedure, recovery room staff, and discharge staff.

a. Have all employees sign an acknowledgement form that they understand the new policy and corresponding procedures, and received training within 14 days of establishment of the new policy

As noted by Haugen, Murugesh, Haaverstad, Eide, and Softeland (2013) wrong site surgery continues to be a problem that can be prevented through the use of a checklist. In 2008, WHO published guidelines to ensure the safety of surgical patients. The guidelines included

In 2003, as an outcome of all the sentinel events reported to the Joint commission lead to the creation of the “The Universal protocol for preventing wrong site, wrong procedures, and wrong person surgery” (Mulloy & Hughes 2008). So, one of the ways that could have potentially prevented the situation from happening at the first place was implementing the universal protocol procedure. According to the protocol the conduction of proper pre as well as post-operating procedures are extremely mandatory. Therefore, by enforcing a standardized routine pre-operating procedure such as verifying the patient as well as the correct site for the procedure, by having the medical staff or preferably the physician marking the operating site with his or her initials before the surgery will be an effective preventive measure (Mulloy & Hughes 2008).

We will make sure that per our hospital policy we will I.D. the site at admission, whenever there is a patient transfer, and at preop we will communicate this with the patient whenever the patient is aware. We will strive to make sure that the surgical sites are appropriately marked per the site I.D. policy and that the patient is interactive in the process when applicable. As part of this policy we will also make sure that all necessary medical records and labs are readily available for the procedure. We will also make sure that all possibly needed equipment and supplies are present.

5. The Patient Safety Officer will train the risk assessment team members on the proactive risk assessment process and how to conduct a proactive risk assessment, including the assessment of risk, itself.

In the second Element of Performance, JACHO names each team member of the team while NCH’s policy only says all members of the team leaving it uncertain who is part of the team. In compliance with JACHO, NCH fails to comply with the third Element of Performance in that they have no policy stating that a separate time-out needs to be initiated if the patient is having two or more procedures and the person performing the procedures changes.

At least half a million deaths per year could be prevented with effective implementation of systemic improvements in operating rooms. Specifically, multiple studies have found implementing the use of the WHO Surgical Safety Checklist would significantly reduce surgical morbidity and mortality due to surgical errors.

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

EP 5 requires a written process for patients who refuse site marking or when it is impossible or impractical to mark the site. This written process is absent in the hospital’s policy. Nightingale’s policy and process must be revised immediately to reflect all the required elements of the standard. Hospital physicians and staff must be educated on the necessary changes and the revised process must be put into action. Once these changes have occurred, I recommend a focused audit to ensure full compliance with the revised policy/process.

Wrong site surgery remains the most frequently reported sentinel event, with 908 wrong site surgeries reported since 1995 (AORN, 2010). During the late 1990’s and early 2000’s there was a tremendous public concern and lack of trust for the medical profession, especially within surgical services. We as healthcare professionals needed to step up to the plate, slow down, and take responsibility to improve the quality of care we provide for our patients. Although there still is some resistance from surgeons and other healthcare professionals, overall there has been a general acceptance to universal protocol.

Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment that provides for proper care and emphasizes patient safety. NCH has shown to be 100% compliant with the majority of standards including: Infection Prevention and Control, Right and Responsibilities to Patients, Human Resources, Transplant

Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013).

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).