Accreditation Audit AFT2 Task 1
Executive Summary
Current Compliance Status

A. Compliance Status – Executive Summary
Nightingale Community Hospital’s is a healthcare facility with a vision to” be the hospital of choice for patients, employees, physicians, volunteers, and the community.” We also state our mission is to create a healing environment, with a passionate commitment to healthcare excellence. Creating this vision and staying true to the stated mission requires that we adhere to the requirements set forth by the Joint Commission. In preparing for the Joint Commission visit there are focus priority areas that will need to be addressed if Nightingale is going to be compliant. The specific focus area addressed in this summary is medication management.
There are three standards that come under the medication management area. The standards are listed in the table below along with their descriptions and summary of whether Nightingale Hospital has the documentation/data to be Joint Commission compliant for the given standard. Standard | Description | Joint Commission Compliance | MM.01.01.01 | The hospital plans its medication management processes. | MetNightingale PoliciesPatient Care Polices: 1. Medication Management, Patient Specific Information 2. Medication Administration | NPSG.03.04.01 | Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. | MetNightingale Hospital NPSG Data: * Average Hospital-Wide Medication Labeling of Containers over the last 12 months = 99.6%. | NPSG.03.05.01 | Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. | Needs ImprovementAverage Adverse Drug Events related to Anticoagulation therapy per 1000 patients days over the last 12 months = 3.4. |

There is an identified risk for patients receiving anticoagulation therapy to have an adverse drug event. Over the course of the year there has been a decline in monthly events, but there will need to be improvement to not only meet the Joint Commission standard but to ultimately keep the patients we render care to safe from harm.
In the Joint Commission survey review from 2 years ago it was noted on standard PC.01.02.01 The hospital provides patient education and training based on each patient’s needs and abilities there was a finding (The Joint Commission E-dition, 2014). The reviewers noted that closed and open medical records in the hospital lacked sufficient evidence that the individual’s ability to learn prior to education was documented. “Studies have shown that insufficient adherence and a low level of patient knowledge about oral anticoagulant treatment are primary causes for complications (Hua, et al., 2011). The rationale for NPSG.03.05.01 states: “To achieve better patient outcomes, patient education is a vital component of an anticoagulation therapy program.” Nightingale will need to look at process improvement focusing on patient education when patients are receiving anticoagulation therapy.
A1. Plan for Compliance Nightingale has 13 months to establish and implement a corrective action plan to ensure 100% compliance with the Joint Commission standards. The table below addresses the elements of performance for NPSG.03.05.01 and whether Nightingale has sufficient documentation to meet the standard.

Standard NPSG.03.05.01Elements of Performance | Description | Joint Commission Compliance | 1 | Use only oral unit-dose products, prefilled syringes, or premixed infusion bags when these types of products are available.
Note: For pediatric patients, prefilled syringe products should be used only if specifically designed for children. | Not Met | 2 | Use approved protocols for the initiation and maintenance of anticoagulant therapy. | Met Patient Care Policy: Monitoring Anticoagulation. | 3 | Before starting a patient on warfarin, assess the patient’s baseline coagulation status; for all patients receiving warfarin therapy, use a current International Normalized Ratio (INR) to adjust this therapy. The baseline status and current INR are documented in the medical record.
Note: The patient’s baseline coagulation status can be assessed in a number of ways, including through a laboratory test or by identifying risk factors such as age, weight, bleeding tendency, and genetic factors. | MetPatient Care Policy: Monitoring Anticoagulation | 4 | Use authoritative resources to manage potential food and drug interactions for patients receiving warfarin. | MetPatient Care Policies: * Pharmacist Review of Medication Orders * Medication Administration | 5 | When heparin is administered intravenously and continuously, use programmable pumps in order to provide consistent and accurate dosing. | Not Met | 6 | A written policy addresses baseline and ongoing laboratory tests that are required for anticoagulants. | MetPatient Care Policy: Monitoring Anticoagulation | 7 | Provide education regarding anticoagulant therapy to prescribers, staff, patients, and families. Patient/family education includes the following:
- The importance of follow-up monitoring
- Compliance
- Drug-food interactions
- The potential for adverse drug reactions and interactions | Not Met | 8 | Evaluate anticoagulation safety practices, take action to improve practices, and measure the effectiveness of those actions in a time frame determined by the organization. | Not Met |

Based on the review of current policies and guidelines, the following recommendations are suggested to better meet the National Patient Safety Goal for Anticoagulation safety. 1. Nightingale will define and implement an anticoagulant program that individualizes the care to each patient using consistent guidelines, standing orders and tools. This will be accomplished by a task force that includes representatives from: a. Patient safety b. Medical directors c. Clinical programs d. Quality e. Risk Management f. Nursing practice g. Pharmacy h. Health Information management i. Lab services
This task force will assess safety processes, identify best practice and facilitate standardization of protocols and processes (Nutescu, et al., 2013). 2. To reduce compounding and labeling errors, the hospital will use only oral unit dose products, pre-filled syringes, or pre-mixed infusion bags when these types of products are available. For pediatrics, pre-loaded syringe products should only be used if specifically designed for this purpose. This will be reviewed as needed by Pharmacy and Therapeutics Committee. 3. The current guideline for initiation and maintenance of anticoagulation therapy will be reviewed, updated and approved by the task force. j. Documented baseline INR will be documented in the medical record for patients on warfarin along with a current INR that will be used to adjust therapy. Compliance for documentation will be monitored quarterly. k. Update policy to include the notification of dietary services when patients are receiving warfarin to make sure food/drug interactions are avoided. l. Update policy to include a programmable infusion pump when heparin is administered intravenously and continuously. m. Update policy to reflect anticoagulation therapy educational needs of staff, patient, and families. i. Provide online accessible patient education fact sheets that address: 1. Warfarin anticoagulation and therapy 2. Warfarin eating plan fact sheet 3. Deep Vein Thrombosis and Embolism Fact Sheet 4. Fact sheets for the different medications used to treat blood clots caused by atrial fibrillation 5. Fact sheets will include follow-up monitoring, the importance of compliance, drug/food interactions and the potential for adverse drug reactions as appropriate. ii. Provide online accessible staff education fact sheets that address: 6. Medication guidelines and information sheets, including pediatric for: a. Disease states b. Novel oral anticoagulants c. Specific medication information iii. Face-to-face interaction to review and reinforce educational material (Nutescu, et al., 2013). 7. This will be documented in the chart and monitored on a quarterly basis. n. Standing order sets will be developed for adult and pediatric appropriate disease processes. iv. The goal is to have computerized provider order entry (CPOE) order sets. Research has shown that CPOE has positive effects on decreasing dosage errors. (Bresnick, 2014)

A2. Justification
A phrase from the Hippocratic Oath states “never do harm” which is first and foremost the goal as we are entrusted with the care of patients. The Center for Disease Control and Prevention states “It is estimated that there are 700,000 emergency department visits and 120,000 hospitalizations due to adverse drug events (ADEs).” The financial impact is staggering with an estimated $3.5 billion spent to cover the extra medical cost due to these events. (CDC -Medication Safety Program, 2014). In a study of anticoagulation-associated adverse drug events, “Anticoagulants are among the most common medications that cause ADEs in hospitalized patients” and it was concluded that most ADE’s among inpatients result from medication errors and so are potentially preventable (Piazza, et al., 2011).
The negative impact of adverse drug events related to anticoagulation therapy is enormous in terms of our patients’ health and adds financial cost to a healthcare industry already facing rising costs. Patient education and engagement play an important part in improved health for the population we serve. We also have an obligation as an organization to improve the quality of care for the patients we serve by providing consistent, efficient, evidence-based care. In delivering this type of care, we can continue to decrease the number of adverse drug event that occur within our hospital.

Bibliography

(2014, July). Retrieved from Western Governor's University: https://cos.wgu.edu/courses/task-stream/AFT2
CDC -Medication Safety Program. (2014, July 27). Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/medicationsafety/basics.html
The Joint Commission E-dition. (2014, July 2). Retrieved from The Joint Commission on Accreditation of Healthcare Organizations[US]: https://e-dition.jcrinc.com/MainContent.aspx
Bresnick, J. (2014, January 22). Clinical Decision Support. Retrieved from EHR Intelligence: http://ehrintelligence.com/2014/01/22/clinical-decision-support-cpoe-get-thumbs-up-from-academics/
Hua, T., Vormfelde , S., Abu, A. M., Scnheider-Rudt, H., Sobotta, P., & Chenot, J. (2011, April 10). Practice nursed-based, individual and video-assisted patient education in oral anticoagulation--protocol of a cluster-randomized controlled trial. BMC Fam Pract, pp. 12-17.
Nutescu, E., Wittkowsky PharmD CACP FASHP FCCP, A. K., Burnett PharmD PhC, A., Merli MD FACP, M., Ansell, J. E., & Garcia MD, D. A. (2013). Delivery of Optimized Inpatient Anticoagulation Therapy. The Annals of Pharmacotherpay, 714-724. Retrieved from Medscape Multispecialty: http://www.medscape.com/viewarticle/804033_7
Piazza, G. M., Nguyen, T. N., Cios, D. P., Labreche, M. P., Hohlfelder, B., Fanikos, J. R., . . . Goldhaber, S. Z. (2011). Anticoagulation-associated adverse drug events. Am J Med, 1136-1142.
Simpson, J. (2014, January 7). LeadQual. Retrieved from Taking Advantage of the QDF (Query Deserves Freshness) Signal: http://www2.leadqual.com/blog/searchengineoptimization-seo/taking-advantage-of-qdf-signal/
Tylor, J. (2014). Chron. Retrieved from Chron.com: http://smallbusiness.chron.com/crm-software-can-benefit-small-business-139.html