Topics: Hospital, Joint Commission, Patient, Nurse, Nursing, Hospital accreditation / Pages: 5 (1486 words) / Published: Aug 30th, 2014


Accreditation Audit Case Study/ Tracer Patient Task III
Crystal Shanaman

Accreditation Audit Case Study/ Tracer Patient Task III

A1. 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

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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