Aft2 Accreditation Essay

1581 Words Mar 16th, 2014 7 Pages
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
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The charge nurse on duty at the time the report is released to the department is responsible for ensuring the physician is notified.
The charge nurse and pharmacist on duty at the time the critical lab is reported will be responsible for ensuring communication with the physician is completed. Every Friday, the manager for each department will collaborate with the pharmacy to audit critical lab reporting and ensure compliance. 100% compliance of reporting to physicians with supporting documentation is expected by the end of the month. At the end of every quarter, the manager for each department will report to the Chief Quality Officer the results of the chart audits. Any discrepancies will result in disciplinary action for the charge nurse on duty at the time of the critical lab report.
To increase compliance with verbal order/read back notations, the hospital will no longer accept verbal orders from physicians. If the physician is on the floor, they will be responsible for entering the order personally. In the instance of telephone orders received from a physician, the nurse receiving the order will accept the order, read the order back to the physician for verification and write “telephone order read back x1” after signing. For example a telephone order received from a physician for Clonidine 0.3 mg should be written as:
TO Clonidine 0.3 mg PO x1 Dr. Physician/Nurse RN, TORBX1
The order will then be faxed to the

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