Executive Summary Wgu

Topics: Patient, Hospital, Medical record Pages: 3 (1095 words) Published: April 3, 2013
Patient Safety Recommendations-Communication
Care, Treatment, and Services
IMPACT| STANDARD| FINDINGS| RESPONSIBLEPARTY| TARGET DATE| ACTION PLAN| 3| IM 02.02.01 element 2The hospital uses standardized terminology definitions, abbreviations, acronyms, symbols, and dose designations. The hospital follows its list of prohibited abbreviations, acronyms, symbols and dose designations.| Review of the National Patient Safety Goal data for December 2012 and January 2013 indicates the hospital continues to use unacceptable abbreviations as identified in the patient care policy Prohibited Abbreviations. The following were identified: * QD * x3d * SC * U| Medical DirectorDirector of NursingPharmacy DirectorDirector of IT| 3/15/13| IT will develop a stop gap measure within the electronic medical record templates that prohibits the use of all unacceptable abbreviations.Staff transcribing orders will obtain clarification by the prescribing licensed practitioner if unacceptable abbreviations are used.Orders received by pharmacy that contain unacceptable abbreviations will not be filled until clarification is obtained.All nursing, pharmacy and medical staff will be educated on the process for clarification for any use of unacceptable abbreviations. The education will be noted in their HR file.20% of all discharged patient’s medical records will be audited on a monthly basis until 6 consecutive months of 100% compliance has been obtained.| 4| MM 04.01.01 element 6Medication orders are clear and accurate.| Review of National Patient Safety Goal Data on Verbal Order/Read Back indicates that the Orthopedic Unit’s statistics are at 62%, nearly 30% lower than the other departments audited.| Director of NursingNurse Manager for Orthopedic Services| 4/1/13| The policy on Verbal Orders/Read Back will be reviewed with all nurses working on the Orthopedic unit and the education will be noted in their HR files.25% of all Orthopedic patients medical...
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