December 2, 2013
RAFT Task 1
Executive Summary for Joint Commission Standards Compliance
Nightingale Community Hospital is a 180-bed acute care hospital that is a not-for profit entity. The hospital is community based and provides leadership in quality health services in which they provide. Their vision is to be the hospital that people choose, the place employees, physicians and volunteers want to work and a hospital of choice for the community. They are committed to providing a healing environment to their patients with a compassionate commitment to healthcare excellence.
The four main areas of focus for the Joint Commission for Nightingale Hospital include Communication, Information Management, Medication Management and Infection Control. The goal of these four focus areas is safety. The goal of safety is the most important because it allows for the best management and treatment of patients. This will guide the hospital’s focus toward the best protocols and policies which will reduce patient harm and errors. Each policy and protocol is specifically designed for each individual facility. Medication Management is the focus area in which I chose to discuss the existing compliance of the organization. The Joint Commission’s ethics for medication management address the critical processes involved and support compliance with the National Patient Safety Goals. “The medication management standards are geared to allow assessment of the organization’s eight essential medication processes” (Manniello, 2011). The eight processes are critical to patient safety and include: planning, selection of medications, proper storage, ordering and receiving, preparation, administration, patient monitoring, and evaluation. Focus will be on the areas which did not meet the Joint Commission ethics and standards. a corrective action plan that will then be suggested to bring the organization back to complete compliance. The goal is to provide the organization with a framework for an operational and secure medication management system.
The focal points which failed to meet 100% compliance with the Joint Commission were: 1. The hospital safely manages high-alert and hazardous medications. High alert medications as defined by the Joint Commission are “ those medications involved in a higher percentage of errors and/or sentinel events, as well as medications that carry a higher risk for abuse or other adverse outcomes” (Joint Commission on Accreditation, 2013). Hospital has no policy in place. 2. The hospital has failed to place a policy into effect for licensed personnel that address the issue of look-a-like and sound-a-like medications that it stores and dispenses. The Joint Commission requires hospitals to take preventative action to reduce and prevent errors that involve medications that can be interchanged and appear on the list. 3. The Safety Reporting System of the hospital has a policy in place for adverse reactions that state it is a voluntary online reporting. According to Joint Commission Standards an adverse reaction must be directly reported to the primary physician and quality assessment team. 4. Patient care policy of pharmacist review of medications that is in place fails to address the allergic reactions of the patient as the number one priority of the pharmacist. According to the Joint Commission policy all medications ordered must be reviewed for patient allergies or potential sensitivities. 5. The hospital has failed to place a policy in the evaluation of the effectiveness of medication management system.

Corrective Action Plan Nightingale Hospital will put into place a High Risk and Hazardous Medications Policy.
Purpose: To identify the most universally used high-risk and high-alert medications at Nightingale Hospital and to define the management of such medications to thereby minimize or prevent medications errors.
Policy: Nightingale Hospital through the use of various committee processes and literature alert (Institute for Safe Medical Practice) will maintain and continue to assemble a complete list of high-risk/high-alert medications. This register will be reviewed quarterly and be revised as needed through a continuous review process. The process will include information from the Institute for Safe Medical Practices, Joint Commission and Drug Manufacturers. Literature will be kept up-to-date and on file for all pharmacy and nursing staff.
Procedure: Pharmacy personnel will be responsible for maintaining, identification and continual updating of medications that are commonly used within the facility. Pharmacy will improve upon and develop new strategies for the reduction of medication errors that are caused by the use of these types of medications.
The hospital will also put into place a policy regarding Look-Alike/Sound-Alike Medications. This will also include the handling of selection and procurement standards for the hospital.
Purpose: To identify the most universally use look-a-like and sound-a-like medications and to define the management of these medications and thereby prevent or minimize potential medication errors.
Policy: Nightingale Hospital through the use of various committee processes and literature alert (Institute for Safe Medical Practice) will maintain and continue to assemble a complete list of high-risk/high-alert medications. This register will be reviewed quarterly and be revised as needed through a continuous review process. The process will include information from the Institute for Safe Medical Practices, Joint Commission and Drug Manufacturers. Literature will be kept up-to-date and on file for all pharmacy and nursing staff.
Procedure: Pharmacy will be solely responsible for the identification, maintenance and updating of the look-a-like/sound-a-like medication list. Pharmacy will then develop and maintain strategies for the reduction of such medication within the facility in order to reduce the potential medication errors.
Safety Reporting of Adverse Reactions will be upgrade within the facility. Adverse drug reactions are common and often go unrecognized and therefore unreported. The aim of the new policy is to prevent avoidable adverse drug reactions.
Purpose: To improve patient safety, eliminating adverse events and supporting a facilitating quality improvement effort by Nightingale Hospital
Policy: Establishment of internal policies and procedures to recognize, trace and examine all adverse events and near misses. Conduct the appropriate cause analysis and develop and implement corrective action plans.
Procedure: Nightingale Hospital must put into place a computerized system that will detect adverse drug reactions early so that physicians can initiate interventions to lessen the effects and severity of the reaction. Staff will complete manual forms to track the adverse events, improve quality and assess the risks. All adverse events must be reported to the Quality Assurance Team.
Nightingale Hospital will rewrite the policy for the pharmacist’s review of medications to include a patient’s potential allergy or sensitivity to a medication.
Policy: A pharmacist will review all medication orders for the correct dosage and instructions before the first dose is ever issued to be given to the patient.
Procedure: The assessment of medications by the pharmacist will include: * Real or potential allergies or sensitivities * Medicinal correctness of a patient’s medicine schedule * Possible duplication of such regimen * Correctness of the medication, the prescribed amount, regularity, route and the mode in which the drug will be administered * Potential/real medication to medication, medication to food, medication to disease and lab test interactions * Any variation of the medication from its original use * Other potential contraindications
Nightingale Hospital will put into place a policy that will form a team of licensed staff members to continually review and oversee the updates to medication policies and protocols quarterly.
Policy: The Pharmacy, Risk Management and Quality Assurance teams shall implement a Medication Management Assessment and Evaluation program. This program will specify a system that will be put into place to ensure medication use within the hospital is conducted in a safe and optimum manner. They will work together with licensed medical staff to develop, implement and evaluate the organizations policies and protocols for medication.
Procedure: The Pharmacy department will provide the fundamental functions as well as the oversee obligations and events in the medication management system. The Risk Management and quality Assurance teams will conduct the evaluations, obtain quantitative data and then present a written report of the findings to the Pharmacy department. Reports shall include but are not limited to: criteria, findings, causes and conclusions and recommendations for improvement.
In conclusion, by placing and enforcing the above mentioned policies, Nightingale Hospital will be in 100% compliance with the Joint Commission’s standards. Continual audits of all policies and protocols with quarterly reviews and recommended changes ensure that the hospital remains in compliance. The goal of safety in Medication Management is the most important because it allows for the best management and treatment of patients. This will guide the hospital’s focus toward the best protocols and policies which will reduce patient harm and errors.

References:
Joint Commission on Accreditation. (2013). Retrieved December 7, 2013, from Joint Commission: https://e-dition.jcrinc.com/MainContent.aspx
Manniello, R. L. (2011, April). Medication Management. Retrieved December 7, 2013 , from HC Marketplace: http://www.hcmarketplace.com/supplemental/9139_browse.pdf