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Wgu Accreditation Audit Aft2 Task 1

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Executive Summary - Preparation for Accreditation Audit

AFT2 Accreditation Audit

September 26th, 2014

Executive Summary - Preparation for Accreditation Audit

Nightingale Community Hospital (NCH) offers comprehensive care for a wide range of conditions and is a leader amongst its peers in providing compassionate and quality care. To meet their main mission of putting patients care first, NCH consistently endeavors to meet and exceed standards set forth concerning medication management by the Joint Commission. This is exemplified in NHC’s clear and concise policies concerning medication administration, medication safety, and anticoagulation therapy. These policies and programs provide the framework upon which NHC meets Joint Commission Accreditation requirements.

Current Compliance Status During the next audit, in 13 months, the Joint Commission has three priority focus areas concerning medication management which includes: 1. Planning of Medication Management Process 2. Labeling of all medications in all areas, all forms 3. Reduce Patient harm associated with anticoagulant therapy Currently NCH has appropriate measures, policies, and programs in place concerning medication management to meet accreditation requirements. Policies and programs are thorough and include protocols for collecting information that would spotlight an area of opportunity for improvement. Through the use of data collection it has been determined that while NCH has made improvements concerning the use of two patient identifiers when administering medication and adverse effects due to anticoagulation therapy, it could still continue to make quality improvements. This is evident in the amount of adverse effects per 1000 patients NCH has had. Towards the beginning of the year 5-6 events per month occurred while the last two months only 2 events per month occurred, with an average of 3.41 events per month for the year. While this shows improvement recently more needs to be done to ensure sustained improvement in this critical focus area. Concerning the labeling of medication, NCH has achieved a 100% rate for 9 out of 12 months, the other 3 months were between 98% and 99% rate of labeling, with an average of 99.67% for the year. Subsequently, it is noted that it is required to have 100% compliance in this area and this area needs to continue to advance and maintain a 100% every month of the year. To increase quality improvement and meet accreditation requirements going forward it is advisable to enhance current policies and procedures to create and sustain a quality improvement culture within the hospital. This will ensure a successful future audit by the Joint Commission.
Corrective Action Plan Concerning the first and the third focus area, while NCH has substantial polices in place regarding medication management there may be an oversight due to the lack of policy with respect to training and re-training employees. The policy should be amended to include for initial training and refresher training on a specified timeline for all employees that are involved with administering medication. This will ensure that all employees have factual up to date information concerning this aspect of their duties. This modification should also be beneficial in regards to lowering incidents of failure in respect to the policies governing the two patient identification and anticoagulation therapy. Training models can also be implemented to help the transitions to new procedures and practices as recommended by the Pharmacy and Therapeutics Committee at NCH. Recommendation for the second focus area includes revising the policy to include the Joint Commission requirement of “Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field” (Joint Commission, 2014). In addition to a policy change conduct an internal audit to ensure compliance with this Joint Commission stipulation. Make changes as necessary and train all affected employees concerning this requirement. In respect to all medication management requirements it would be advisable to hire an independent external third party auditor to review our policies and how the policies are carried out in the field. The gives the benefit of identifying areas of opportunity for improvement before and adverse event takes place. The current internal review process is designed to correct problems after an event has already taken place. An outside audit would have the advantage of prevention and outside point of view that may be in a better position to observe issues that internal auditors may be complacent about.
Importance of Medication Management to Accreditation Adverse effects to medications and medication errors are a leading cause of harm within a hospital setting such as NCH. According to Thompson-Moore and Liebl (2012) “Medication errors are the most common type of error affecting patient safety in hospitals” (Thompson-Moore and Liebl, 2012, pg. 431). For this reason it is a leading concern from both an accreditation and liability point of view. Nearly every patient who is admitted to a hospital will receive a medication during part of their stay or during their treatment process. NCH’s primary goal is to provide outstanding patient care through healthcare excellence. In order to deliver upon their primary mission, and keep accreditation, they must make continual process improvements to lessen the amount and severity of harm caused my medication errors and adverse events. At its core the existing medication management policies and programs provides a strong foundation to fulfill this commitment to excellence in patient care. The addition of the aforementioned recommendation will solidify in place a medication management program that will continually strive for quality improvement and a reduction in patient harm caused my medication errors and adverse events.

Joint Commission (n.d.) NPSG 03.04.01 Retrieved from:
Thompson-Moore, N., & Liebl, M. G. (2012). Health care system vulnerabilities: Understanding the root causes of patient harm. American Journal Of Health-System Pharmacy, 69(5), 431-436. doi:10.2146/ajhp110299 Retrieved from:

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