Western Governors University
Joint Commission Compliance Audit
Task 2
AFT2 Accreditation Audit
By Cricket Besse 055895
Nightingale Community Hospital
Sentinel Event
Registrar, registered child (3 year old patient), obtained insurance card and entered demographics. She was then taken to pre-op where the nurse told mother that once in the OR the surgery would take about 45 minutes and then she would go to recovery. The mother informed the pre-op nurse that once her daughter went into the O.R. she needed to run a quick errand involving an older sibling and would return in time to pick her up once she got out of recovery. The mother gave the pre-op nurse her cell phone number phone number with instructions to contact her
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Pain intervention-assesses pain levels, makes complete notes on charts, communicates to the PACU nurse & physician. Completes any forms required by facility. Makes patient observation, Takes patients vital signs (blood pressure, pulse and temperature). Ensures patient is breathing properly, and administers oxygen when needed. Must be able to react to signs of negative change, call for assistance and begin CPR if necessary. Discharge Nurse
Review surgeons written discharge instructions. Goes over discharge with patient. Has patient sign discharge instructions Hospital Security Guard
Will ensure the safety of the hospital premises. Helps in evacuation drives in times of fire and threats. Interacts with hospital staff of all departments with special emphasis on drug storage areas, infant care units, and ward for mentally ill patients and trauma care. Personnel Issues
The Hospital environment can offer some practical challenges that could be barriers in communications. Many patients have individual needs and this can impede on a nurses time and emotions. Nurses put in long hours and have a high patient/nurse ratio or shortage of healthcare workers. Nurses/personnel have to deal with emergencies in an already challenging and busy hospital setting. Dealing with patients takes mental acuity and emotional support and sensitivity. Hospital guidelines might not have sufficient communication practices among personnel in place.
Improving
Specifically, the pre-op nurse who acquired the parental contact information, or upon being informed that the mother would be leaving the facility did not document it in the patient chart or pass it along to the O.R. nurse.
I supervise the unit’s operations and oversees specific employees at the BHT II and BHPP II level. I am also part of a multi-disciplinary clinical team to provide recovery-based services for consumers in varying levels of crisis. Others include performing nursing assessment, developing a medical service plan and obtains and executes medication orders from psychiatric prescriber. As an RN supervisor, I oversees and maintains medication and medication records in accordance with Agency policies and State regulations. I also coordinates medical care with psychiatric prescriber and PCP. It is my responsibility to serve as a role model of professional behavior at all times.
Inspect and manage medical records to insure that the correct information is being used for the right patient.
While extremely beneficial, this tool can also become a hindrance when supplies are not restocked or are placed in the wrong location. Another important member of this floor is the charge nurse who acts as a liaison between patients, nurses, shifts, and hospital administrators. The charge nurse does not have a set of patients assigned to them specifically, but helps nurses to get caught up when they fall behind and acts in a generalized way to keep the floor functioning. The floor receptionist helps to direct patient calls to the appropriate personnel, but this person is only present at certain times during the day. Also visiting at any given time are physicians, chaplains, respiratory therapists, wound nurses, IV therapists, physical therapists, occupational therapists, and a variety of other hospital personnel. With all of these individuals coming and going, this floor is constantly abuzz with movement as everyone works together to help the patients who populate this floor receive the health care they need.
A physician directs your treatment at the hospital. Doctors can easily access patient information, test/lab results, and send out E- prescriptions to pharmacies. Registered nurses wear navy blue and white scrubs. They are responsible for planning, coordinating and providing for a patient’s care. They use the information system daily to update, evaluate and record patient symptoms, review patient treatment plans and their measure progress. Other members of nurses that use the health system are licensed practical nurses, and student nurses. They are all managed by the RN and oversee all the patient care and activities. Allied health professionals wear tan and black scrubs. They perform diagnostic tests and therapy required for the care and treatment a patient needs. These allied health professional include laboratory staff, radiology techs, physical therapists, and respiratory therapists. “They may play roles in evaluating and assessing a patient’s needs, keeping the physician and others informed of the patient’s progress and caring for the patient” (Association, 2012). Clerical Assistants are volunteers at this hospital and does not provide care for patients but they do have access to information systems under the supervision of administrators. They answer telephones, proof-read, perform data entry, and sort
ability of patients and assist them if needed to ensure the quality and hygiene of all patients. With
They are able to perform patient care by IV and oral medication administration, cardiac monitoring, airway management, blood transfusion, wound care etc… They are accountable to implement family central patient care.
According to the Society of Emergency Medicine Physician Assistants (Society of Emergency Medicine Physician Assistants, 2013), the role of a physician assistant in the ED is to provide emergency care under the supervision of a licensed physician. The extent of care they provide varies by state law, facility policy, education of the PA, and how much the supervising physician feels comfortable delegating work (Britnell, Dodd, Vella Gray, & Brochu, 2015). For example, at Memorial Regional Hospital, the PAs working in the ED are allowed to perform I&D (incision and drainage of abscesses) and laceration repairs, but they are not allowed to perform intubations or place IVs under ultrasound guidance (Levy, 2016).
Effective communication is crucial aspect of nursing yet too often is placed low on the priority list, especially at shift change. Information related to the care of patients is frequently disseminated at a crowded, noisy nurse station with several nurses rushing to leave and others attempting to get the information necessary to plan care and limit the constant distractions. It is this interaction that allows for information vital patient safety information to be communicated including the acuity of patients.
.-Evaluate the patient’s progress and change the plan of care to achieve the goal from admission until discharge.
Provide and maintain life support and airway management and help prepare patients for emergency surgery.
The services we do are helping with preparation, monitoring, dispensing, oversight, and correct documentation of patient’s prescriptions. There are many things we have great knowledge in like, we must know the medicine’s name and what it is used to treat. Reviewing the orders you received to make sure they are all correct, no mistakes are made. Labeling, preparing, and dispensing the prescription that the patient has given you. Calling patients for information about the drug they are prescribed or in person information feeding. Keeping record of merchandise (medicine) that is located in the back. Inventory expiration date checking and getting rid of the drug. Follow and know the rules and procure of the common P.T, also must be educated and know the rules of the Health Insurance Portability and Accountability (HIPPA). CPR certified is another must have in the P.T field.
Unlike the MA job duties, nurses’ roles and responsibilities are different from the MA. The nurse are responsible to do phone calls to and from patient, faculty, doctor and other staff members all day long. They help manage day-to-day operations of the health care clinic, maintain health records, documenting each patient contact and updating patient profiles, ensure confidentiality during visits and telephone contact, distribute non-prescription medication after appropriate assessment, encourage health maintenance and promotion through counseling and awareness activities and assure that patients understand instructions.
Consistently draws blood competently and expediently with as little patient discomfort as possible and records phlebotomy requisitions in logbook.
Communication plays a vital role in the healthcare setting, as the relationship with the healthcare professional sets the tone of the care experience and has a powerful impact on patient satisfaction. It is “the shared process in which messages are sent and received between two or more people which are made up of a sender, receiver, and message in a particular context” (cite, date). This essay highlights the importance of, and some common barriers to, effective communication in the healthcare setting. It involves many interpersonal skills such as effective observation, questioning and listening, giving feedback, recognizing and removing barriers.