Jenny Windler
Student ID: 000329547
Accreditation Audit (AFT2)
Task 1

A. Compliance Status

Nightingale Community Hospital is a complete and leading healthcare facility that believes in providing the best quality care to all of their patients. As part of Nightingale’s mission to put the patient first, the hospital must meet medication management standards set forth by the hospital and the Joint Commission. Medication management often involves the efforts of multiple services and disciplines. It is part of Nightingale’s policy that a patient’s information is accessible to a physician, pharmacist or nurse in the management of a patient’s medication. Nightingale Hospital has all the policies in place that the Joint Commission looks for to keep the hospital accredited.

A1. Plan for Compliance
In reviewing the safety of using medication associated with Anticoagulation Therapy, Nightingale Hospital needs some improvement. There was only one month out of the year that patients did not experience any adverse effects related to Anticoagulation Therapy. Numbers were high at the beginning of the year and tapered off by the end of the year, but Nightingale Hospital should be experiencing more months where there are no adverse events. In combination to the Joint Commission’s finding 2 years ago regarding the lack of documented evidence that the patient’s ability/readiness to learn, learning preference, or educational needs were assessed and documented in the file, we have much to improve on in this area. It is noted in the Joint Commission standard that to reduce the likelihood of patient harm, that effective anticoagulation patient education is needed. As noted in the Rationale for NPSG.03.05.01, effective anticoagulation patient education includes face-to-face interaction with a trained professional who works closely with patients to be sure that they understand