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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. Improving these areas would be just one step toward increasing patient care and satisfaction at this hospital. There are three areas to focus on that Nightingale Community Hospital is not in compliance with according to the Joint Commission ...view middle of the document...

(McDownell, 2007) Nightingale Community Hospital has a commitment to healthcare excellence. With this excellence it is essential the hospital perfects their communication among employees and decreases the reporting times.
The second is hospital-wide medication labeling. Medication labeling is not only labeling the medication but the printed information, any wrapping or packaging inserts that come with the medication. The national patient safety goal data of medication management survey showed that this hospital has been out of compliance hospital wide with labeling medications in 3 out of the last 12 months. The three months where Nightingale Community Hospital scored low in the survey resulting in three months out of compliance where April, May and September. The Food and Drug Administrations requires that all medication labeling must be scientifically accurate and provide clear instruction to health care practitioners for prescription drugs and to consumers. All instructions must included dosage, what if a patient miss a dose, special instruction such as take this medication with food, warn not to give to an other person and general storage instruction. However, labels are not to be all-inclusive but should provide all-important information to educate the patient on that medication is being proscribed or given. (Health Encyclopedia, 2012) All other months the hospital scored 100%, leaving their average with some improvement in the communication and verification process.
The third area is adverse drug events related to anticoagulation therapy. Nightingale Community Hospital survey results showed throughout the year they have had a decrease in patients with adverse reaction. However, this does not mean they did not have patients with reactions. There have been a large number of patients with reactions to anticoagulation therapy that could have been prevented. The survey results showed that most of the year they have between 2-6 reactions per 1000 patient days. During the Joint Commission study they found that patients records where not reevaluated immediately prior to the administration of medications. (The Joint Commission: LD.03.01.01, 2012) Implementing protocols that will expand monitoring and communication hospital-wide will help prevent reactions. Developing and enforcing dosing and monitoring guidelines for all anticoagulation therapy will increase awareness of drug reactions and allow for medical records verification among all hospital professional. With verification of medications and patient records will result in less drug reactions. (Franco, Maxwell, Green & Barthol, 2009) Medication reactions can been minimize even more with proper handling, patient care and medical records management.
Being the hospital of choice for patients, employee, physicians, volunteers and community members is Nightingale Community Hospital’s vision while providing quality to its patient care. There are some area the hospital needs to improve to...

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