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Raft Task 1 Essay

1684 words - 7 pages

EXECUTIVE SUMMARY

PURPOSE
The purpose of this report is to assess the compliance of Nightingale Community Hospital (NCH) in accordance with the Joint Commission’s National Patient Safety Goals for 2012. This report will focus exclusively on the Priority Focus Area of Communication and its subsequent standards:
* UP.01.01.01 – Conduct a preprocedure verification process.
* UP.01.02.01 – Mark the procedure site.
* UP.01.03.01 – A time-out is performed before the procedure.
BACKGROUND
NCH is 13 months away from its next Joint Commission audit. It is imperative that NCH is in complete compliance with the Joint Commission.
METHODOLOGY
In order to determine the degree of ...view middle of the document...

01.01.01. This requires the matching of the items that are available in the procedure area to the patient.
Please refer to Table 01 on the next page for a comprehensive overview.

Priority Focus Area | Joint Commission Standard | Elements of Performance | Is NCH Compliant? | Recommended Solution(s) |
| | Description | Yes | No | |
Communication | UP.01.01.01Conduct a preprocedure verification process. | 1. Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site.Note: The patient is involved in the verification process when possible. | | X | Include precise language on the Preprocedure Hand-Off (PHF) form that specifies verification of the correct:1a. procedure to be performed;1b. patient on whom the procedure will be performed;1c. site where the procedure will be performed. |
| | 2. Identify the items that must be available for the procedure and use a standardized list to verify their availability. At a minimum, these items include the following:-Relevant documentation-Labeled diagnostic and radiology test results-Any required blood products, implants, devices, and/or special equipment for the procedure | | X | Include precise language on the PHF form that specifies the existence of the:2a. signed procedure consent form and its subsequent attachment.Include precise language on the PHF form that specifies the existence of the following categories and commencing with a conspicuous subheading:2b. nursing assessment2c. preanesthesia assessment2d. radiology images and scans2e. pathology and biology reports |
| | 3. Match the items that are to be available in the procedure area to the patient. | X | | n/a |
Table 01: NCH Compliance on Standard UP.01.01.01

FINDINGS
Standard UP.01.02.01.
NCH is in compliance with the first two parts of the Elements of Performance related to standard UP.01.01.01. However, the last part reflects some deficiencies. In order to remedy this, it is suggested that NCH include unambiguous language indicating that the procedure site will be marked by a licensed independent practitioner. As it stands, this language is omitted from the existing Site Identification and Verification form.
Please refer to Table 02 on the next page for a comprehensive overview.

Priority Focus Area | Joint Commission Standard | Elements of Performance | Is NCH Compliant? | Recommended Solution(s) |
| | Description | Yes | No | |
Communication | UP.01.02.01Mark the procedure site. | 1. Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety. | X | | n/a |
| | 2. Mark the procedure site before the procedure is performed and, if possible, with the patient involved. | X | | n/a |
| | 3. The procedure site is marked by a licensed...

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