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Accreditation Audit Essay

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 patient is unable to mark the site, the policy states that the physician will be called to mark the site. The policy states that the mark shall be made in permanent black marker so it will remain visible after skin preparation, and also in a location that will remain visible after sterile draping is in place. The policy also includes circumstances in which the marking will be unable to be performed based on the location of the surgery being in an area that is unable to be marked. Standard: UP.01.03.01: A time-out is performed before the procedure.

Nightingale Community Hospital has an adequate procedure in place for the time-out performance. Within the Site Identification and Verification Policy, the Time-Out Procedure complies with JC standards. A time-out is to be conducted immediately prior to performance of the procedure, it is initiated by the nurse or technologist, it involves all personnel involved in the procedure, the team members agree to a minimum of patient identity, correct site, and correct procedure to be performed, and all of this information is documented in the record, including those involved and the duration of the time-out. The only issue not addressed fully is the possibility of multiple procedures occurring on the same patient by different practitioners, and in that case, an additional time-out needs to be done for every new procedure.

The Communication priority focus area is an extremely important area for any hospital. This is a common sense area that should be able to reach complete compliance. A wrong-patient, wrong-site issue should never arise and is completely avoidable. In 2010, Joint Commission reported that wrong-patient/site surgeries continued to be the most frequently reported sentinel event(Spath 2011).Jay Arthur states that JC reports between four and six wrong-site surgeries per day(2011). The World Health Organization believes that at least 500,000 deaths per year could be prevented if the WHO Surgical Safety Checklist was correctly implemented.

These numbers, when compared with the possibility of 100% compliance, are astounding and completely avoidable. Nightingale Community Hospital is well on their way to avoiding these types of sentinel events through usages of proper protocol, procedures, and policy as is seen by the upward trend from their last year of self-checks. With continued diligence and appropriate modifications made, this can be an area that NCH, and any other hospital can be fully compliant in.

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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