Nightingale Community Hospital (NCH) is currently preparing for its triennial Joint Commission survey which is expected in approximately 13 months. The Joint Commission primary focus areas for NCH are Information Management, Medication Management, Communication, and Infection Control. The primary focus area outlined in this summary is Communication.
The Joint Commission has three standards in which NCH is evaluated. Currently, NCH is non-compliant with standards UP.01.01.01 and UP.01.02.01. They are:
* UP.01.01.01 - Conduct a pre-procedure verification process.
* UP.01.02.01 - Mark the procedure site.
As stated in the policy "Site Identification and ...view middle of the document...
Verification of the procedure being performed must take place before the patient is transferred out of the pre-op area. The patient can be asked to verbally verify the type of procedure. If the patient is unable, a family member or legal representative must verify the procedure. This process must involve reviewing all documents relating to the procedure and documentation that the process has been completed.
All patients will be identified by using at least two patient identifiers such as name and date of birth before providing care. This will be done in conjunction with identifying the patient using the patient's ID band. Labels with the patient's demographics will be used to identify all documents and materials needed for the procedure. All forms will be changed to have a section for the label to be attached. The rule of thumb is that if it isn't documented, it didn't happen.
The section of policy "Site Identification and Verification (Universal Protocol)," Marking the Operative/Invasive Site suggests that the patient or the patient's family member is responsible for marking the site. According to Joint Commission standards, only medical personnel involved in performing the procedure may mark the site with verification by the patient. All references to the patient marking the site must be removed and replaced with authorized medical personnel.
There must be a universal explicit mark for site location used throughout the hospital. The mark must be made using a permanent marker that will remain visible after the skin prep and must be visible when the surgical drapes are applied. The policy contradicts itself as to what mark is made for a lesion or mole and isn't sufficiently large and clear enough for adequate visualization. There must be adequate education and training mandated to staff involved in the procedure regarding the proper procedure for site marking.