This website uses cookies to ensure you have the best experience. Learn more

Accreditation Audit Essay

2823 words - 12 pages

RAFT –Task 2 Root Cause Analysis A-1. Sentinel Event A sentinel event is an event that happens expectantly in a healthcare facility that could result possible death, physical or mental injury to patients unrelated to natural causes of the patients illness as defined by Joint Commission (www.joint commission.org). On the afternoon of Thursday, September 14, at approximately 12:30 p.m. a ‘Code Pink’ (child abduction alert) was called when a minor child/patient, Tina, was discharged to the care of her father without the knowledge of her mother with whom she was admitted with. Tina was registered into the hospital system by Katie Jessup, hospital registrar, who entered all proper demographics ...view middle of the document...

Tina was located by local law enforcement within a half hour her arrival at the hospital. Tina was unharmed and in the care of her father. He had taken her to his home waiting to hear from her mother. No charges were filed. Tina’s mother was informed by Nightingale’s CEO that the matter would be investigated to prevent this type of error from reoccurring.

A-2. Personnel According to my own hospital experience, I referred to East Jefferson General Hospital’s definition to the following positions filled in a hospital: Registrar—the position of a registrar is that they are the first point of contact during the admission phase. The registrar’s duties include, the collection of patient information, valid identification, verifying insurance information, making copies of said information. The registrar also inputs patient information into a computer system and verify necessary physician referrals and insurance authorizations. Also they are responsible for assigning bed, and carry out procedures to admit, transfer or discharge patients. In addition, the registrar is usually the first person seen in the admission process therefore other administrative duties may be required. The registrar also explains financial responsibility to the patient and also process payments, such as co-pays and bills due (www.ejgh.org). During the sentinel event the patient registrar carried out all duties specified above, however she did not ask for proper identification nor did she ask if Tina’s mother was the custodial parent. Surgeon—responsibilities include consultations with colleagues, patients, and patient families. The surgeon is held accountable to conduct evaluations on patient’s illnesses. In addition, the surgeon is responsible for preforming the surgery and/or initiating a referral. He is accountable to counsel and advise patients. In conclusion, the surgeon is responsible for accurately documenting a patients chart and inspecting and monitoring area of incision (www.ejgh.org). During the sentinel event the role of the surgeon was carried out without any mishaps however his office did not forward custodial information which may have prevented this error. It is not his job to do this, however, information pertinent to the patient should be made available to the hospital. Chief Nursing Officer (CNO)—is in charge of the entire nursing staff at hospitals and hospital institutes. CNO’s are responsible for the management of nurses in their department by providing feedback, training, support, and disciplinary actions when called for. CNO’s are also accountable for the development of programs and procedures that will help the hospital institutions run efficiently and promote growth (www.ejgh.org). The role of the CNO was that of an ineffective leader in that she was unavailable (why?) when the incident occurred, however she took responsibility and accountability.

Pre-op Nurse—is responsible for working closely with the attending surgeon. Her list of...

Other Papers Like Accreditation Audit

The Joint Commission Essay

1312 words - 6 pages collaboration system. In 1951, several stakeholders, such as the ACP, the AMA, the AHA, and the CMA, join to create the Joint Commission on Accreditation of Hospitals (JCAH). This organization serves to provide voluntary accreditation for health care agencies. This accreditation system inspires health care organizations to “provide safe and effective health care of the highest quality and value” (The Joint Commission, 2013, para. 3). Therefore, by

Health Care Governance Essay

766 words - 4 pages killand heart a disease…….kills four times more yearall other types people than die from of accidents.” Sunday Times, 19 Dec 1999 WAY OUT !!! SO; Clinical Governance is “About quality and how it can be achieved and guaranteed through our service to our patients “ (Royal College of Nursing, 2003:9). Effective Risk Management components: Clinical Audit : • Clinical audit is a way that healthcare professionals can measure the

Mr.Yussif

8674 words - 35 pages required to compete for the audit business of the largest firms) under threat from a claim in the US, for example, would be unlikely to be protected by a cap on liability in the UK. The EC, after examining the proposed acquisition of Andersen UK by Deloitte,22 did not hold liability responsible for the firm's collapse, but rather loss of reputation (with the brand asset devalued), dissolution of the network and the loss of US SEC accreditation

Internal Controls

914 words - 4 pages . · Design assurance activities continue during the implementation phase to ensure designs are complied with (see Recommendation 6 above). · A robust and reliable audit trail for Security Accreditation and in-built checks on compliance are in place. · A check is carried out to verify that security operating processes have been defined and implemented. Summarised output from the formal Security Accreditation process should form part of regular

It Audit Guide

4838 words - 20 pages IT [pic] Australian Government Department of Defence Information System Audit Guide VERSION 11.1 January 2012 Table of Contents 1. Introduction to Accreditation 4 2. The Information System Audit – Checklist 7 2.1. What is an Information System Audit? 7 2.2. Why is an Information System Certification needed? 7 2.3. Assessing an Information System’s Security Risks 7

Accred Audit

613 words - 3 pages policies and procedures are being followed in accordance to the standards set by the Joint Commission. III. Improvement Timeframe The corrective action plan will go into effect immediately, in order to establish and maintain patient safety and the safety of the staff as well. If this is not implemented immediately, the hospital will fail audit. References The Joint Commission. (2013). The Joint Commission Comprehensive Accreditation And Certification Manual. Retrieved September 3, 2013, from https://e-dition.jcrinc.com/MainContent.aspx

Computer Science Xyz Company

1026 words - 5 pages from the same from the CMS Team, and this approval is taken in the change management meeting. Certification and Accreditation Company is following all the certification and accreditation and they have documented the same. System Security Plan ABC Inc. has deployed https protocol; they are following other security measures as well and have documented the same too. Operational Controls 6. Personnel Security The users are not trained on

Key Influences Impacting Apollo Group, Inc

558 words - 3 pages Netherlands. Interestingly, Apollo Group noted in its 2005 annual report that their operations are not impacted by inflation.Government Influences Governmental influences on Apollo Group stem primarily from education related regulations. As the nation's largest recipient of federal government sponsored student loan funding, mainly through Title IV programs, the company is subject to a litany of regulations and audit procedures. Apollo Group must also

Income Taxation

1779 words - 8 pages contested in good faith. Accreditation of tax practitioners and agents Tax practitioners and agents (TAPs) are persons who are engaged in tax practice and thus are required to apply for accreditation with the BIR, they are as follows:   1. Those who are engaged in the regular preparation, certification, audit and filing of tax returns 2. Those who are engaged in the regular preparation of request for ruling, petitions for reinvestigation

Ethics

1359 words - 6 pages accreditation office, told board and commission members. Vanderford laid out findings from an investigative audit that ranged from an alleged rape on the high school campus that went unreported to insufficiencies in the district's special education department and a failure to keep sensitive student records confidential. (Royals, Clarion-Ledger) Just this statement alone speaks volumes of the disservice students of Tunica County have suffered. One of

Contingency Plan

813 words - 4 pages seeking shareholders’ approval at each AGM. | | BOARD COMMITTEES MK LAND HOLDINGS BERHAD | MALAYSIAN ARLINE SYSTEM BERHAD | * The Board of Directors had established the following committees in compliance with the Bursa Main Market Requirements and Malaysian Code on Corporate Governance: * Audit Committee * Nomination Committee * Remuneration Committee * The Board delegates certain responsibilities to Board Committees

Related Essays

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 Background: 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

Raft Accreditation Audit Case Study Task I

3345 words - 14 pages Executive Summary of Accreditation Audit June 2012 I prepared and reviewed an accreditation audit for Nightingale Community Hospital to organize and ensure compliance with Joint Commission standards for our hospital. We are preparing for a site visit that should occur within the next 13 months. I have reviewed the current compliance status of our hospital and will explain our corrective action plan that will ensure compliance with the Joint

Accreditation Audit Essay

1586 words - 7 pages Executive Summary - Infection Control and Prevention Current Compliance Status for Joint Commission Accreditation Nightingale Community Hospital is committed to providing healthcare excellence, a healing environment and to be the choice for patient care. In order to continue to provide quality healthcare services in accordance with our values of safety, community, teamwork, and accountability Joint Commission Accreditation provides

Accreditation Audit Essay

3086 words - 13 pages A. Compliance Status When a patient checks into Nightingale Community Hospitals they believe the hospital will put there care first and provide quality medicine. Looking at the recent compliance reports there are areas of patient care this hospital needs to improve in. Reporting critical results within 60 minutes, labeling medication containers and reactions with anticoagulation therap.0y are areas that this hospital needs to improve upon