The Joint Commission is scheduled to see Nightingale Community Hospital for its triennial accreditation study within the following 13 months. The intent of this papers is to supply senior leading with an lineation of the hospital’s current conformity position in the Priority Focus Area of Communication. Recommendations for disciplinary action are included in this papers which are designed to convey the organisation into full conformity in the countries where shortages have been identified. The Priority Focus Area of Communication includes 3 Joint Commission ( JC ) criterions relative to Universal Protocol. These 3 criterions. which are constituents of the National Patient Safety Goals. are aimed at guaranting the right process is performed on the right patient at the right site. UP. 01. 01. 01 requires the organisation to carry on a pre-procedure confirmation procedure prior to the start of any process. The hospital meets this criterion by following its policy titled “Site Identification and Verification ( Universal Protocol ) ” which describes the procedure that is used prior to the start of any operative or invasive process. The hospital’s usage of the “Pre-Procedure Hand-Off” checklist provides the certification required to show conformity with the criterion. Because of the criticalness of this criterion. I recommend a focussed medical record reappraisal to mensurate conformity with the usage of the pre-procedure checklist.
If the audit reveals the checklist is completed systematically. full conformity with the criterion will be verified and no farther action will be required. UP. 01. 02. 01 requires the organisation to tag the process site before the process is performed. The Site Identification and Verification policy describes the procedure for taging the operative site nevertheless the policy as written does non run into the full purpose of the criterion. The policy states the patient will place and tag the operative site. Component of Performance 3 of the criterion requires the process site to be marked by the accredited independent practician who is accountable for the process and will be present during the process. EP 5 requires a written procedure for patients who refuse site marker or when it is impossible or impractical to tag the site. This written procedure is absent in the hospital’s policy. Nightingale’s policy and procedure must be revised instantly to reflect all the needed elements of the criterion. Hospital doctors and staff must be educated on the necessary alterations and the revised procedure must be put into action. Once these alterations have occurred. I recommend a focussed audit to guarantee full conformity with the revised policy/process. UP. 01. 03. 01 requires a time-out before the start of the process.
The Site Identification and Verification policy describes the time-out procedure nevertheless the policy falls short of to the full run intoing the purpose of this criterion. EP 2 describes which team members must take part in the timeout. EP 3 requires a time-out before each process when two or more processs are being performed. and EP 5 requires certification of the time-out. These 3 elements are losing from the infirmary policy/process and therefore alterations to the process/policy are necessary to include these 3 elements. Nightingale’s Safety Report reveals increasing conformity ( approaching 100 % ) with the time-out procedure. nevertheless as mentioned above. EP 5 requires certification of the procedure. In add-on to the policy alteration. I recommend the development of a alone signifier which will be used to document completion of the time-out and the names of the participants in the time-out. Once these alterations have been implemented. I recommend extra auditing to guarantee full conformity with certification of the time-out procedure. The Joint Commission studies more than 900 Sentinel Events related to incorrect site surgery occurred between 1995-2010 ( The Joint Commission. 2010 ) Their research found that 70 % of the clip. the root cause of incorrect site surgery was communicating failure ( Mulloy and Hughes 2008 ) .
When it occurs. incorrect site surgery can be lay waste toing for patients and it can go forth a lasting. negative impact on the surgical squad. Surgeons are at hazard of losing their licence and infirmaries hazard losing reimbursement. When these events occur the hazard of judicial proceeding exists every bit good. Wrong-site. wrong-procedure and wrong-person surgery can be prevented! The Priority Focus Area of Communication as it relates to Universal Protocol is indispensable to Nightingale Community Hospital for forestalling incorrect site surgery and advancing a safe environment within our infirmary. The hospital’s Site Identification and Verification policy was developed with good purposes to run into that end. The 3 cardinal elements to forestalling incorrect site surgery ; 1 ) pre-op confirmation procedure ; 2 ) taging the operative site ; and 3 ) taking a clip out. are all present in the policy nevertheless there are extra elements required by the Joint Commission that are losing from the policy and leave the organisation and patients at hazard.
In order to populate up to our core value of safety and to guarantee full accreditation with the Joint Commission. it is of import for the organisation to to the full run into all the elements of public presentation. The alterations outlined within this papers will beef up the policies and processs that are intended to forestall injury to patients and will convey the organisation into full conformity with the JC criterions. These actions will finally guarantee that a genuinely safe environment exists within the walls of Nightingale Community Hospital for the benefit of its patients. associates and the community.
The Joint Commission. ( 2010. 11 23 ) . Sentinel event statistics as of September 30. 2010. Retrieved from hypertext transfer protocol: //www. jointcommission. org/assets/1/18/Stats_with_all_fields_hidden30September2010_ ( 2 ) . pdf Mulloy. D. F. . & A ; Hughes. R. G. ( 2008 ) . Patient safety & A ; quality: an evidence-based enchiridion for nurses. Rockville. MD: Agency for Healthcare Research and Quality. Retrieved from hypertext transfer protocol: //www. nlm. National Institutes of Health. gov/books/NBK2678/