Accreditation Audit Essay

1032 words - 5 pages

Regulatory and Compliance:
Hospital Communication and Wrong Site Surgery Prevention
March 21st, 2014
Accreditation Audit

Regulatory Audits and Compliance
Hospital Communication and Wrong Site Surgery Prevention
Wrong Site Surgery is costly and horrifying experience for the patient, the physician and the hospital. It is considered a preventable medical error. In 1999, the Institue of Medicine report, To Err is Human states that “clinicians were unaware of the number of surgery-associated injuries, deaths, and near misses because there was no process for recognizing, reporting, and tracking these events.” (LT Kohn, 2000) Physicians and nurses do not wake up ...view middle of the document...

Taking a ‘time-out’ (The Joint Commission / Joint Commission Resources, 2004)
Nightingale Summary
Nightingale Community Hospital is a 180-bed, acute care, not for profit community hospital. The following is a review of the communication priority focus area. To ensure compliance there are a couple revisions to the policy and process that must be implemented. I have attached a gap analysis to assist in reviewing the components required and needs to meet compliance. Below is a summary of the review.
1. Standard UP.01.01.01: Conduct a pre-procedure verification process (The Joint Commission / Joint Commission Resources, 2004)
a. The Nightingale Community Hospital Universal Protocol appears to meet all areas of compliance. It could be enhanced by adding the statement that “the patient is involved in the verification process when possible.”
2. Standard UP.01.02.01: Mark the procedure site
b. There is an area of non-compliance per the Site Identification and Verification Protocol. The policy states that the nurse providing the care to the patient will complete the site verification and the patient will mark the site. Both of these are not in compliance with the standard. Dr. DiGiovanni and colleges performed a study and found that when patients mark the site after given a set of instructions, 40% of patients marked the site incorrectly! (CW DiGiovanni, 2003) It is important that the hospital revise the policy and procedure to ensure the physician performing the surgery is marking the site. (The Joint Commission / Joint Commission Resources, 2004)
c. In addition the policy does state alternative ways to mark the site when it is not anatomically possible or appropriate, (mucosal surfaces, rectal procedures), but does not state alternatives for patients that do not allow marking or have tattoos that decrease visibility of the marking. This is required to be written. (The Joint Commission / Joint Commission Resources, 2004)
3. Standard UP.01.03.01: A time-out is performed before the procedure.
d. It appears the hospital is almost completely in compliance per the policy. However, a statement concerning the situation when 2 or more procedures are being performed on the same patient – an additional time out...

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