Task 1: Executive Summary
Assessment Code: AFT2
Executive Summary: Nightingale Community Hospital Joint Commission Compliance Standards for Communication Focus Area
Recently there has been much media focus on preventable medical errors. Any google search will produce a multitude of news articles that all report that preventable medical errors is now the third leading cause of death in the United States. Poor communication plays a role in most if not all of these errors. In fact the Joint Commission (2012) has published that an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer ...view middle of the document...
The first standard, UP.01.01.01 focuses on the preprocedure verification process and has three required elements of performance. These elements require that a preprocedure process to verify the correct procedure, for the correct patient at the correct site using a standardized list to verify that necessary items are available for the procedure is implemented. Additionally patient involvement in the process whenever possible and matching items that are to be in the procedure area to the patient are also required. Nightingale has developed a standardized list that is published. A policy stating that this checklist will be accomplished and that the patient will participate in a preprocedure verification has been approved by the Surgery Leadership Committee. Nightingale is currently compliant on this standard, however improvements for this standard would include improvements to the checklist. The checklist does not include stating the procedure and the site of the procedure. Additionally it does not highlight that the patient should be involved in this process. In order to strengthen the process, these should both be included in the checklist. The Surgery Leadership Committee needs to be tasked with reviewing and improving the checklist. This should be a formal review and the revised checklist should be presented to the Executive Committee of the Medical Staff for approval and then implemented hospital wide. This review and approval should occur in the next two months. The new checklist should then be implemented and feedback should be solicited from all areas of the hospital that use the list. This feedback should be collected for a three month period by the patient safety program manager. This feedback should then be presented to the Executive Committee for further review to ensure that the improvements on the checklist are effective.
The second standard, UP.01.01.02 focuses on marking of the procedure site. There are five required elements of performance. The first requires that the facility identify those procedures that require marking of the site. Nightingale is compliant in this element as those procedures are identified and published in the Universal Protocol Policy as mentioned above. Elements 2-5 require that the site be marked before the procedure is performed, that the patient be involved whenever possible, and that this be performed by the licensed independent practitioner who is ultimately accountable for the procedure. Additionally it is required that the method of marking and type of mark be used consistently throughout the hospital and that a written alternative process is in place for patients who refuse site marking or when marking is not possible or practical. Nightingale is in compliance with these elements with the exception of one. Nightingale’s policy requires that the nursing staff have the patient mark the site during the preoperative phase in a standardized fashion using a permanent black marker. This meets...