Aft2 Task 1 Accreditation Audit

Good Essays
With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.
Standard: UP.01.01.01: Conduct a preprocedure verification process. Nightingale Community Hospital has a Site Identification and Verification policy and procedure. Within this policy, and Preoperative/Preprocedure Verification Process is addressed. There is also a Preprocedure Hand-Off form present. This form is a bit misleading as it is essentially a hand-off form in general with a few extra boxes possible for check-off. To prepare for inspection and audit, NCH should create and implement a form for use within the Operating Theater or wherever procedures are performed, such as bedside procedures. This form needs to be more specific in addressing at least the minimum requirements by JC. The form needs to cite that all relevant documentation is present, such as signed consent form, nursing assessment, preanesthesia assessment, history and physical. The form also needs to specify that the necessary diagnostic and radiology test results, rather they be images and scans, or biopsy reports, and properly displayed and labeled. Finally, to fulfill the minimum requirements by JC, any and all required blood products, implants, devices, and special equipment needs to be labeled and matched to the patient.
Standard: UP.01.02.01: Mark the procedure site. NCH covers the procedure site marking standard fairly well within their Site Identification and Verification Policy. It mentions that site marking is needed for those cases involving laterality, multiple structures, or levels. Several times in their policy NCH mentions that it is best to have the patient involved, if at all possible. If the



References: Arthur, J. (2011). Lean six sigma for hospitals: Simple steps to fast, affordable, flawless healthcare. New York, NY: McGraw-Hill. Spath, P. L. (2011). Error reduction in health care: A systems approach to improving patient safety (2nd ed.). Hoboken, NJ: Jossy-Bass. WHO (2013). WHO | Safe surgery saves lives. Retrieved from http://www.who.int/patientsafety/safesurgery/en/ [Last Accessed November 5, 2013].

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