A. Provide a summary of the following aspects of a root cause analysis related to the sentinel event found in the attached Accreditation Audit Case Study – Task 2 Specific artifacts by doing the following:
1. Describe the sentinel event.
2. Explain the roles (i.e. responsibilities, etc.) of the personnel present during the sentinel event.
3. Discuss the barriers that may impede effective interaction among the personnel present during the sentinel event.
a. Propose ways to improve interactions among the personnel present.
4. Discuss a quality improvement tool to be used to conduct the root cause analysis.
B. Outline a corrective action plan to ensure that the sentinel event does not recur by doing the following:
1. Recommend a risk management program or process change to ensure that the sentinel event does not recur.
a. Discuss resources available to support these changes.
C. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
D. Demonstrate professional communication in the content and presentation of your submission.
Western Governors University
January 12, 2022
Table of Contents
Information management 3
Executive summary 3
Status of compliance 3
A correction plan 5
Areas justification 6
As the senior leadership team at Nightingale Community Hospital organizes for an accreditation audit, they must analyze their present compliance status. To examine their compliance position, the team requirement have a comprehensive understanding of Joint Commission to ensure that they are following the rules of their accrediting agency. The effort of this investigation would be on information management of Nightingale’s. The assessment would comprise a compliance status for Nightingale’s Information Management, a corrective plan for areas which do not meet Joint Commission norms, and an understanding of the value of Information Management.
The Joint Commission’s rules include a section on abbreviations, which states that hospitals must avoid using dose descriptions, symbols, abbreviations, or acronyms that are unsuitable. This requirement is met by Nightingale, as evidenced by their Healthcare Policy: Prohibited Abbreviations documentation. All of the forbidden abbreviations stated on the Joint Commission’s Element of Performance are included in Nightingale’s document. The exact specifications about the use of the trailing zero in the usage of medication-related documents are not included in Nightingale’s publication (Nelson, 2012). The hospital’s document also fails to specify when the restricted list is in effect.
Furthermore, by providing consistent terms and meanings, the Nightingale hospital may maximize its compliance also with the Joint Commission norm. While the hospital is successful in addressing proper abbreviation and dose indication, it is lacking in conventional medical terminology information. An Admission Orders form is used at Nightingale Community Hospital. For example, when listing their medication dosing, they appropriately use the trailing and leading zero Joint Commission standard. It also uses standard abbreviations for lab and tests (i.e. EKG). It also specifies the name of substance for non-standard abbreviations.
After assessing Nightingale’s Information Management articles, it can be concluded that Nightingale does not appropriately define the components of complete medical records (Englebright, 2014). There are no supporting documents that demonstrate Nightingale’s compliance with the Joint Commission’s standard in providing patients and employees with an understanding of the components that make up the medical record.
Nightingale’s Admissions Orders form provides some insight into what a patient’s medical records include. This form includes patient allergies, requested orders, medication information, and diagnostic testing information. Per the Joint Commission standard, a medical record must include facts required to support the evaluation and to explain the requested treatment while the Admissions form excels in documenting the services being requested apron admission, the form lacks reasoning for while the admission is being requested. For example, the form does not include previous diagnostic testing, abnormal vitals, or such information that would justify the need for admission. This information is important for continuity of care from one provider to another as the patient transfers care when admitted.
Nightingale’s Admission Orders form requests that all orders be dated and time-stamped. This form complies with the Joint Commission’s guideline that requires that all entries in the medical record are dated.
The Joint Commission requires that hospitals conduct a review of medical records to ensure that documentation is performed promptly and is legible and accurate. Nightingale’s National Patient Safety Goal (NPSG) data shows the hospital’s review of errors in labeling patient specimens and errors in the use of inappropriate abbreviations. While this shows that Nightingale is conducting some review of their accuracy when documenting patient information, it is minimal and their review could improve. The review should expand to assess the hospital’s timeliness, legibility, and authentication.
The communications artifacts used to assess Nightingale’s Information Management show that the hospital is compliant in ensuring the appropriate use of abbreviation and dose designations. However, the hospital will also need to add an element that specifies the standardized terminology and the corresponding definitions to ensure that there is no miscommunication between medical professionals and with patients. One way to do this is by creating a document that serves similar functions to a glossary (Hegge, 2013). The document can be used to establish standard terminology practices. Additionally, the appropriate use of standard terminology can he audited and assessed by reviewing patient charts to ensure that providers and clinical personnel are adhering to the terminology, abbreviations, and symbols that are compliant with the Joint Commissions’ guidelines. Additionally, the hospital would need to ensure that the appropriate terminology document is readily available to the clinic staff. The document can be saved electronically on the hospital’s intranet or posted in each office.
Nightingale does not properly define the components of complete medical records in any of their artifacts used for Information Management. For example, the Admissions Order form does not include all of the components of the patient’s medical records- it does not include the problem list or treatment notes. Consequently, the Admission Order form should be recreated to include more components of the patient’s medical record that would facilitate the transfer of care to another provider (Hegge, 2011). When recreating the document, it should include the patient’s problem list, family history, clinical notes from the provider placing the order that supports the diagnoses, and medication history. Providing all components of the medical record minimizes clinical errors and ensures that the requested services are justified appropriately.
Nightingale does perform an ongoing review of medical records as demonstrated in their NPSG data. However, the hospital could improve on its review by assessing more areas in Information Management. The plan of action in their area includes conducting monthly reviews of provider clinical charts to ensure that the providers are closing their charts on time, their written information is legible, and the included information is supported with the completeness of data and observations. Additionally, this information can be used to coach clinical staff and catch potential mistakes in patients’ medical records that could ultimately lead to patient harm.
Englebright. (2014). Defining and incorporating basic nursing care actions into the electronic health record. Journal of Nursing Scholarship, 57.
Hegge. (2011). The lingering presence of the Nightingale legacy. Nursing Science Quarterly, 162.
Hegge, M. (2013). Nightingale’s environmental theory. Nursing science quarterly, 219.
Nelson. (2012). Notes on Nightingale: The influence and legacy of a nursing icon. Cornell University Press.