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Aft2 Accreditation

In: Business and Management

Submitted By 10cannon
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Compliance Status
“Effective communication is a cornerstone of patient safety” (The Joint Commission, 2007). Nightingale Community Hospital has areas of improvement needed in the area of communication. The following are the results of an audit for National Patient Safety Goal (NPSG) compliance. * Hospital –wide compliance of reporting critical results within 60 minutes with supporting documentation present is 82% at its highest. * Verbal Order/Read Back – 7 departments are not at 100% with the Orthopedic department the lowest at 62% compliance * Unacceptable Abbreviations used included “qd” used 9 times in January, “x3d” was used 3 times in January, “sc” was used 10 times in January and “u” was used 17 times in January and 63 times in December. * Time-Out was only at 100% in December.
These are all communication issues that failed the processes that are currently in place.
Plan for Compliance
To become compliant with reporting of critical lab results, the lab technician will notify the charge nurse of the critical lab result as soon as the result is noted. The lab technician will then enter in the comment section of the lab report which nurse the results were verbally provided to, the time they were provided and the reporting technician’s name. The report will then be released for printing to the appropriate department. The charge nurse will be responsible for notifying the physician when the report is received from the lab. Each department will be issued a colored sticker to place on the lab report to notate the date and time the physician is notified, the physician the results are reported to and the nurse calling the report. The charge nurse will audit each chart at the beginning of the shift to ensure all labs drawn that morning have a sticker indicating the physician has been notified for any critical result. Any lab result found to not…...

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