December 2, 2013
RAFT Task 1
Executive Summary for Joint Commission Standards Compliance
Nightingale Community Hospital is a 180-bed acute care hospital that is a not-for profit entity. The hospital is community based and provides leadership in quality health services in which they provide. Their vision is to be the hospital that people choose, the place employees, physicians and volunteers want to work and a hospital of choice for the community. They are committed to providing a healing environment to their patients with a compassionate commitment to healthcare excellence.
The four main areas of focus for the Joint Commission for Nightingale Hospital include Communication, Information Management, Medication Management and Infection
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The focal points which failed to meet 100% compliance with the Joint Commission were: 1. The hospital safely manages high-alert and hazardous medications. High alert medications as defined by the Joint Commission are “ those medications involved in a higher percentage of errors and/or sentinel events, as well as medications that carry a higher risk for abuse or other adverse outcomes” (Joint Commission on Accreditation, 2013). Hospital has no policy in place. 2. The hospital has failed to place a policy into effect for licensed personnel that address the issue of look-a-like and sound-a-like medications that it stores and dispenses. The Joint Commission requires hospitals to take preventative action to reduce and prevent errors that involve medications that can be interchanged and appear on the list. 3. The Safety Reporting System of the hospital has a policy in place for adverse reactions that state it is a voluntary online reporting. According to Joint Commission Standards an adverse reaction must be directly reported to the primary physician and quality assessment team. 4. Patient care policy of pharmacist review of medications that is in place fails to address the allergic reactions of the patient as the number one priority of the pharmacist. According to the Joint Commission policy all medications ordered must be reviewed for patient allergies or potential sensitivities. 5. The hospital has failed
Preparing for The Joint Commission, Nightingale Community Hospital reviews areas of compliance and non-compliance. A periodic performance review, which is a self-evaluation, is utilized by Nightingale Community Hospital, to prepare for The Joint Commission. The Joint Commission has eighteen accreditation requirements. (Commission, 2013) The periodic performance review found the hospital to be compliant and non- compliant in the following areas:
In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.
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 healthcare systems of Switzerland and the United States are quite similar in some aspects and vastly different in others. In Switzerland, the healthcare is universal and available to all. It is provided by private individual insurance companies and subsidized by the government when needed. Basic health insurance is required to be purchased within 3 months of residency or after birth and is an individual’s choice as to what carrier they choose. Of course, there are exceptions to this mandate but they are very few.("Healthcare in Switzerland," “n.d.”, para. 1) Because of this requirement, 99.5% of the population in Switzerland has
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This hospital is a 65-bed rural hospital but it is the job of every hospital to give the best patient care possible. With a
* Have a written policy in place, which describes the local procedure for recording of unwanted medication to be returned to the pharmacist.
Take each bag of popped popcorn and count the individual kernels that did not pop and record the data on the chart. Perform this for each
mitigate these points assessments will be made in how to best mitigate the failure and what would need to be done to
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The organization provides the usual array of inpatient services expected in a moderate-sized community hospital. A local nursing home
Nightingale Community Hospital's care and treatment are planned to ensure that they are appropriate to the patient's needs and severity of disease, condition, impairment, or disability. Furthermore, care is supposed to be planned and provided in an interdisciplinary collaborative manner by professionals. The hospital assesses pain in every patient in addition to planning operative
The Joint Commission is part of the pharmacy laws and was formed in 1951 as a not for profit organization and is used for the safety of patients and pharmacy workers. The Joint Commission developed a “Do Not Use List” to help both the doctors and pharmacy workers take notice to the mistakes that can be made with just one mark in the wrong place or not on the prescription at all. There are many examples but just one is QOD and Q.O.D this is a difference of every day versus every other day, and could make someone have a hard time getting over an illness or becoming something different1. If a pharmacy tech thinks that a prescription does not look like it is written correctly, he/she should contact the prescribing
Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013).