Task 4

1183 Words Dec 17th, 2012 5 Pages
| Task 4 | | | Monica DeWitt | |

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Current Compliance Status
The hospital is compliant in with the National Patient Safety Goals (NPSG) in the following areas: staff is using 2 identifiers when providing care, correctly transfusing patients, maintaining a healthy patient care environment by complying with the Center for Disease Control (CDC) and World Health Organization (WHO) hand hygiene guidelines, continuing evidence-based best practice to prevent or reduce the risk of catheter-associated urinary tract infections (CAUTI), identifying patients at risk for suicide.
Within the rest of the accreditation requirements the facility was compliant with the following elements:
EM-emergency management
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Labeling issues-The lack of labeling as well as pre-labeling can put the patient at risk. The unit sited for this is the Operating Room.
Annual test-This is a basic safety test that is used to ensure patient and staff safety. The area sited was EOC.
Fire Drills- This is vital to ensure staff has practiced emergency procedures. While auditing the fire drill history it was noted there were gaps in completing the required quarterly drill for each shift. The third shift lacked a drill in the first quarter and the third quarter. The fourth quarter was lacking a drill during the second shift. The area sited was EOC.
The units that have the greatest opportunity for improvement include 3E, 4E, OR and telemetry.
Staffing Patterns
Within the staffing effectiveness report, most data collected indicated a downward linear trend. This downward trend is a positive outcome. However, 4E has an upward linear trend which needs to be improved. The linear trend of nursing hours compared to the number of falls and pressure ulcers indicate an increase in nursing hours do not guarantee drop in falls or pressure ulcers. The performance trends show a gradual increase in the number of falls and pressure ulcers. A closer look is needed to identify reasons for the correlation between greater nursing hours and increased falls. This may be due to a need for increase in nursing staff and limiting the number of hours the nurse can work

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