Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013).
The Standards of Universal Protocols (UP) are: UP 01.01.01 Conduct pre-procedure verification process
UP 01.02.01 Mark the procedure site
UP 01.03.01 Perform a Time-Out before the procedure.
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Root cause investigation. Stahel, Mehler, Clarke and Varnell (2009), tell us that “wrong site and wrong patient procedures have been defined as "never-events" which are theoretically 100% preventable and thus should never occur”. They maintain that even with the practice of Universal Protocols, these “never-events” continue to happen for a number of reasons starting with “the degradation of the Universal Protocol to a robotic-hackneyed type ritual will distract from the requisite focus” (Stahel, et. al., 2009). Other reasons include:
· Multiple procedures performed concurrently or consecutively on the same patient complicating the application of the Time-Out specific to the surgery.
· Addition of secondary safety issues to the official Time-Out reducing the focus away from the protocol’s primary mission Joint Commission, Priority Focus Process Summary “examples of Quality Improvement Activities” (Joint commission, 2013), in detail: The first example used is to design a new service. This service will educate the patients so they have full understanding of what “Time-Out” means and its importance. Guidelines already state that whenever possible, patients should be involved in the universal protocols. In addition to this, patients should be educated about the Time-Out process ahead of time and