Topics: Hospital, Joint Commission, Patient Pages: 8 (1486 words) Published: August 29, 2014

Accreditation Audit Case Study/ Tracer Patient Task III
Crystal Shanaman

Accreditation Audit Case Study/ Tracer Patient Task III

At Nightingale Community Hospital, our value regarding safety is “we believe that excellence begins with providing a safe environment. We put our patients first as we seek to exceed the expectations of our customers with superior service, outstanding clinical care and unsurpassed responsiveness.” (Nightingale Community Hospital, 2007, p. 2) In order to achieve excellence in safety, we often preform safety checks. One of these checks recently preformed was of a 67 year old patient who presented for a hysterectomy. She ended up with complications and subsequent treatment for these complications, all care was provided by Nightingale Community Hospital. Mistakes were made with this patients care and corrective actions will be taken. It is cases like these we strive to correct, in order to become “the hospital of choice for patients, employees, physicians, volunteers, and the community.” (Nightingale Community Hospital, p. 3) In order to learn and grow from the mistakes made with our tracer patient, we must identify specific mistakes made and develop a corrective action plan to address the improvements we are going to make.

According to the information provided by our tracer patient’s worksheet, it was determined the patient presented for “laparoscopic hysterectomy that was converted to an open procedure due to excessive bleeding approximately five weeks prior to hospitalization.” After examining our patient’s worksheet, or fact sheet, a few items throughout their care with us was not up to standards.

First mistake found was our tracer patient did not have an admissions assessment within the 24-hour window, starting with the time of admissions. The tracer patient’s physical was done over 72 hours after admission. Second, the staff reported completing a functional assessment but there was no documentation supporting this claim in her chart. Third, the nurse evaluated the need for an advance directive, found none to be present, and requested the family bring one with them. The family never followed through and did not provide it. Fourth, the nurses did not update the tracer patient’s plan of care since the surgery, and this assessment was done 5 weeks after surgery upon re-admittance. Fifth, a pain assessment is supposed to be done within an hour after pain medications are given. The night before this assessment, the follow up was done over an hour after the pain medication was distributed 4 times. Sixth, the tracer patient’s oxygen tanks were not secured properly and her room’s air vents were dirty. Seventh, the nurse was not able to explain range order or give a proper range in milligrams. Eighth, hand off communication is poor when patient transfers units and or providers. The SDS, OR nurse and PACU nurses completed all evaluation tasks properly.

As you can see, many steps required for safety were either incomplete or overlooked. In order to bring this tracer patient up to the standards of the joint commission a corrective action plan needs to be made. For this assessment I am going to concentrate on the issues of medication range orders and communication during the hand off process. Medication range orders are very important because they can prevent over fusing and under dosing. Over dosing has obvious consequences or poisoning and even death, under dosing can lead to the patient being in unnecessary pain. The hand - off process is very important and was addressed in prior assessments. This is where most mistakes within a hospital take place. A hand-off can include when a patient goes from one department from another or even when there is just a shift change. In our previous case, the disorganization or the hand off lead to one of Nightingale Community Hospital’s...

References: (2009). Palliatives Drug Care (University of Texas). Texas State: University of Texas, MD Anderson Cancer Center, Volume VII Book A Medical Staff, Chapter Medical Staff Approved Policies, Policy Number XX.
Joint Commission. (2014). PC.02.02.01: The Hospital Coordinates the patient’s care, treatment, and services based on the patient’s needs. (The Joint Commission). : Joint Commission.
Nightingale Community Hospital. (2007). Nightingale Community Hospital Brochure [Brochure]. Nightingale Community Hospital: Author.
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