Accreditation Audit Raft 1

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  • Published : September 15, 2012
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Executive Summary
Even though Nightingale Hospital has a very detailed Site Identification and Verification Protocol, some areas do not meet JHACO’s standards. Updating the Universal Protocol and Preprocedure Hand-Off Check sheet will not only bring the facility into compliance but may eliminate any potential failure in communication between patient, caregiver and provider.

Areas that require further documentation will be on the following Elements of Performance:

A.Compliance Status
UP.01.01: Conduct a preprocedure verification process
Documentation is lacking which demonstrates nursing and preanesthesia assessments were completed •Process does not indicate that diagnostic and radiology test results are correctly labeled and properly displayed •There is no area on Procedure checklist which indicates blood products, implants, devices, and / or special equipment for the procedure have been accounted for UP.01.02.01: Mark the procedure site

Policy should emphasis, as listed in the JHACO standard, “sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety” •Procedure does not emphasis that markings must be made large and clearly, leaving no room for misinterpretation. •Procedure does not indicate adhesive markers are not the sole means of marking a site •Procedure does not indicate that an alternative method of marking premature infants must be used instead of permanent markers

UP.01.03.01: A time-out is performed before the procedure
Procedure does not document that a time-out must occur when two or more procedures are performed on the same patient and the individual performing the next procedure changes

A1. Plan for Compliance
UP.01.01: Conduct a preprocedure verification process
Update Preprocedure Hand-Off Checklist to include nursing and preanesthesia assessments were completed and in the patient’s chart •...
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