AFT2 Task 4: Nightingale Hospital

1598 Words7 Pages
AFT2 Task 4

A1.

There are currently 251 standards that must be met in order to receive accreditation from the Joint Commission. In current state, Nightingale Hospital is in compliance with 234 of the standards. The main issues with compliance lie within the following areas:
· Environment of Care
· Leadership
· Record of Care
· Life Safety
· Information Management
· Medication Management
· Provision of Care, Treatment and Service
· Universal Protocol
· National Patient Safety Goals
· Medical Staff

When Nightingale Hospital receives the accreditation from the Joint Commission, it will ensure their patients that they made a significant effort to meet rigorous standards to ensure their patients are cared for in a safe and caring environment.
…show more content…
Verbal orders are authenticated within the time frame specified by law and regulation.”

The time frame that Nightingale Hospital has specified is 48 hours. The current trends reflect that this standard is only being met approximately 85% of the time.

Prohibited Abbreviation – Currently, Nightingale is auditing the usage of abbreviations “cc” and “qd”. These abbreviations should not be used at any time according to Joint Commission Standard IM.02.02.01.

Joint Commission Standard IM.02.02.01 (2013), “The hospital effectively manages the collection of health information. The hospital follows it list of prohibited abbreviations, acronyms, symbols, and dose designations, which include: U, IU, Q.D., QD, q.d., qd, Q.O.D., QOD, q.o.d, qod, trailing zero, lack of leading zero, MS, MSO4, MgSO4.”

Current audit trends reflect that these abbreviations are still being used several times per month.

Fire Drill – Nightingale Hospital requires that one fire drill is performed per shift, per quarter. The Joint Commission standard EC.02.03.03 requires this same
…show more content…
The linear data shows that falls and nursing care hours are steadily moving in an upward trend with no correlations noted. The graph for the pressure ulcer does not have the axis labeled appropriately, therefore unable to determine exactly what is happening. There is also no legend stating what each line represents.

Intensive Care Unit
According to data, the nursing care hours did not show any direct relation to patient falls. There wasn’t any evidence of less staff equaling more patient falls, even when nursing hours were increased, there were still falls. The main reason for additional falls could have been increased patient load during “sick” season and patient being confused due to being medicated. Bed alarms need to be used and staff need to round more frequently. Recommendation of gathering different forms of data so that the root cause of the falls can be determined.

The actions developed to improve VAP seemed to have been a major factor in reducing VAP during FY09. The spikes in September and February VAP do not correlate with the nursing care hours. The same amount of nursing care hours are consistent through the rest of the year and there are no cases of

More about AFT2 Task 4: Nightingale Hospital

Open Document