Executive Summary The Joint Commission is scheduled to visit Nightingale Community Hospital for its triennial accreditation survey within the next 13 months. The purpose of this document is to provide senior leadership with an outline of the hospital’s current compliance status in the Priority Focus Area of Communication. Recommendations for corrective action are included in this document which are designed to bring the organization into full compliance in the areas where deficits have been identified.
The Priority Focus Area of Communication includes 3 Joint Commission (JC) standards relative to Universal Protocol. These 3 standards, which are components of the National Patient Safety Goals, are aimed at ensuring the correct
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The Joint Commission reports more than 900 Sentinel Events related to wrong site surgery occurred between 1995-2010 (The Joint Commission, 2010) Their research found that 70% of the time, the root cause of wrong site surgery was communication failure (Mulloy and Hughes 2008). When it occurs, wrong site surgery can be devastating for patients and it can leave a lasting, negative impact on the surgical team. Surgeons are at risk of losing their license and hospitals risk losing reimbursement. When these events occur the risk of litigation exists as well. Wrong-site, wrong-procedure and wrong-person surgery can be prevented! The Priority Focus Area of Communication as it relates to Universal Protocol is essential to Nightingale Community Hospital for preventing wrong site surgery and promoting a safe environment within our hospital. The hospital’s Site Identification and Verification policy was developed with good intentions to meet that goal. The 3 key elements to preventing wrong site surgery; 1) pre-op verification process; 2) marking the operative site; and 3) taking a time out, are all present in the policy however there are additional elements required by the Joint Commission that are missing from the policy and leave the organization and patients at risk. In order to live up to our core value of safety and to ensure full accreditation with the