Nightingale Hospital Regulatory Audit
HDB

Nightingale Hospital Regulatory Audit
Nightingale Community Hospital is an innovator of high quality care and patient centered services. The hospital vision and mission focus on all stakeholders in the health care community and their role in either delivering or receiving excellence in care. The services offered at Nightingale are comprehensive and include: General Medicine; Critical Care; Emergency; Oncology; Cardiology; Telemetry; Vascular; Neuroscience; Orthopedics; Imaging; Obstetrics; Nursery; Endoscopy and Surgical Services. The administration pledge to the community the core values of Community and Teamwork, as well as Accountability and Safety. Standards that can be improved upon to meet or exceed Joint Commission compliance are taken very seriously.
The hospital is now 13 months away from an anticipated Joint Commission visit. There are four areas for review that hospital administration is focused on for improvement. These areas include information management, medication management, communication and infection control. Medication management, specifically policies governing the use and safety of anticoagulant therapy is the key area of focus in this executive summary and will be the target of a corrective action plan.
Joint Commission NPSG.03.05.01 standard description is to reduce the likelihood of patient harm associated with the use of anticoagulant therapy. In the first quarter of the year there were on average six anticoagulant related adverse events per 1000 patient days. Second quarter there were seven/1000 patient day adverse events total. The third quarter saw an increase cumulatively over the previous quarter with nine total events, but a decline in the trend per month. The fourth quarter results showed steady decline with seven total but the last two months of the year showed the least amount of adverse events. There were two/1000 patient days in both November and December. The goal of any hospital, specifically the pharmacists and the nursing staff is to deliver zero medication errors, regardless it be anticoagulant or otherwise. Nightingale has implemented two robust policies to address errors: Pharmacist Managed Warfarin Dosing and Monitoring Anticoagulation.
Corrective action needs to include the findings and focus on three critical things. 1. Who needs to take corrective steps? This can be a group, individual or the system. 2. What needs to be addressed and how. This can include several elements such as the medication itself, an upgrade to the dispensing system or staff training. 3. When? What is the timeline for the corrective action. The “Pharmacist Managed Warfarin Dosing” policy purpose is to provide guidelines to inpatient pharmacists for independently dosing warfarin when physicians delegate that authority to them. . In this policy there is a preprinted order that requires a check or circle. This puts the patient at risk in that anyone can check or circle the order. The pharmacist can circle back to the ordering physician if unclear. But sometimes in rushed situations that does not happen. A more clear and consistent policy would be for the ordering physician to initiate a written or verbal order for the initiation of anticoagulant therapy to be “monitored per pharmacy” thereafter. For this corrective action the physician and pharmacists are the who. The what, is requiring an initial written or order for all anticoagulant therapy. When, should start immediately to avoid further medication errors.
The “Monitoring Anticoagulation” sets for to ensure the safety and timeliness of warfarin, unfractionated heparin and low molecular weight heparin anticoagulation for the acute care areas. This policy puts a high level of responsibility on the nursing staff. The nurse is to notify the physician when platelets are less than 100,000 or there is a greater than 50% drop in count. They must also obtain a baseline aPTT and on an ongoing basis based on pre-printed orders. It is incumbent upon the nurse to understand the importance of this duty, to obtain the labs and report these values timely. Corrective action would dictate that a charge nurse be assigned to oversee all anticoagulant labs needing to be drawn and to follow up on and report results. Nurse in-servicing on the importance of and consequences of anticoagulant therapy needs to be made a routine part of staff training. Nurses must demonstrate their understanding of lab values and importance of timely reporting. This needs to be implemented on a rolling basis with all nursing staff within 30 days.
Medication errors are most often attributable to human mistakes and regardless of metrics should remain a focus of review for all healthcare institutions. Hospitals should be a place where those who are ill or need treatment seek safety, care and comfort. There is no greater tragedy than to be harmed when seeking help. It is common knowledge that medication errors are a leading cause of preventable medical death. Anticoagulant therapy is used routinely in hospitals for those who come in for acute and sudden illness such as venous thromboembolism, atrial fibrillation, and acute coronary syndromes such as heart attack. Anticoagulants are lifesaving. However, these drugs if not monitored and adjusted properly can have detrimental: bleeding, bruising, need for transfusion if not lethal side effects. Nightingale Community Hospital is well on its way to improving anticoagulant related medication errors. By taking the corrective steps, NCH will meet Joint Commission standards and be 100% compliant. This is not only imperative for the Hospital’s outcomes, but also for every patient who enters the doors.