Patient 453355 Tracer at Nightingale Community Hospital
Patient Tracer Summary
Patient 453355 Tracer at Nightingale Community Hospital To provide an accurate assessment of the systems and processes for the delivery of care, treatment, and services at the Nightingale Community Hospital, weekly patient chart reviews of patient medical cases is performed using The Joint Commission tracer methodology for a thorough review of current services and possible deficiencies. Recently, the medical record for patient 453355 was reviewed in order to trace their care through departments and services at the hospital. This patient was recently admitted to the hospital with a post-op wound infection and the recent surgical stay records were chosen by the Risk Management Department to be assessed and evaluated using the tracer methodology to audit Nightingale Community Hospital’s compliance with selected Joint Commission standards. During the tracer for patient 453355, a Surgical Patient Tracer Worksheet was used to review the actions taken during the patient care process from arrival to leaving. Upon review of the Surgical Patient Tracer Worksheet, a deficiency was identified with the read back process when a critical value is called to a caregiver. During the tracer review, the staff member who was interviewed did not describe the read back process for receipt of critical values or describe how it was documented in the MD notification screen. As part of the Joint Commission Provision of Care requirements, when receiving calls with critical values or test results, staff must record the read back process to verify the information prior to taking action on a verbal order or verbal report of a critical test result (The Joint Commission, 2013).
Patient Tracer Summary To assure compliance not only within the surgical department but hospital wide, a hospital task force was created with representatives from the Laboratory, Imaging,...