The Joint Commission is scheduled to visit Nightingale Community Hospital for its triennial accreditation survey within the next 13 months. The purpose of this document is to provide senior leadership with an outline of the hospital’s current compliance status in the Priority Focus Area of Communication. Recommendations for corrective action are included in this document which are designed to bring the organization into full compliance in the areas where deficits have been identified. The Priority Focus Area of Communication includes 3 Joint Commission (JC) standards relative to Universal Protocol. These 3 standards, which are components of the National Patient Safety Goals, are aimed at ensuring the correct procedure is performed on the correct patient at the correct site. UP.01.01.01 requires the organization to conduct a pre-procedure verification process prior to the start of any procedure. The hospital meets this standard by following its policy titled “Site Identification and Verification (Universal Protocol)” which describes the process that is used prior to the start of any operative or invasive procedure. The hospital’s use of the “Pre-Procedure Hand-Off” checklist provides the documentation required to demonstrate compliance with the standard. Because of the criticality of this standard, I recommend a focused medical record review to measure compliance with the use of the pre-procedure checklist. If the audit reveals the checklist is completed consistently, full compliance with the standard will be verified and no further action will be required. UP.01.02.01 requires the organization to mark the procedure site before the procedure is performed. The Site Identification and Verification policy describes the process for marking the operative site however the policy as written does not meet the full intent of the standard. The policy states the patient will identify and mark the operative site. Element of Performance 3 of...
References: The Joint Commission. (2010, 11 23). Sentinel event statistics as of September 30, 2010. Retrieved from http://www.jointcommission.org/assets/1/18/Stats_with_all_fields_hidden30September2010_(2).pdf
Mulloy, D. F., & Hughes, R. G. (2008). Patient safety & quality: an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.nlm.nih.gov/books/NBK2678/
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