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The Joint Commission's Patient Safety & Quality Findings
Summary of Joint Commission Findings for Strong Memorial Hospital
Survey Dates: October 15-19, 2007
Requirements for Improvement
- Accreditation Participation Requirement 8: Reporting of patient care concerns to the Joint Commission
- National Patient Safety Goal 8: Accurately and completely reconcile changes in patient medications across the continuum of care
- Provision of Care Treatment and Services 8.10: Pain is assessed in all patients
- National Patient Safety Goal 2: Improve communication among caregivers
- Medication Management 2.20: Medications are properly and safely stored
- Human Resources 1.20: Staff qualifications are appropriate for the job responsibilities
- Leadership 3.90: The leaders of the organization develop and implement policies and procedures for care, treatment, and services
- Environment of Care 5.20: The environment meets all Life Safety Code fire safety requirements
1. Accreditation Participation Requirement 8: Reporting of Patient Care Concerns to the Joint Commission
- The hospital provides information to its patients/families about how to notify the Joint Commission if there are concerns about the quality of patient care or safety.
What did the Joint Commission find during their review?
The Joint Commission did not see information on patient rights posters and in the admission packet telling patients and families they have the right to notify the Joint Commission about patient care/safety concerns, and specifically how this would be done.
Why is this important?
Patients and their families have the right to high-quality care and to be safe while they receive care. If they feel that level of care is not received, then there needs to be a way for patients or families to notify an oversight group to investigate these concerns to help prevent harm to patients.
This is what we are doing about it:
There are existing posters in public places throughout the hospital and outpatient clinic locations about a patient’s right to speak up about their care. This information is also in the admission packet for patients admitted to the hospital. A group from the hospital reviewed the information on the posters and in the admission packet and noted that there was information about the hospital complaint process and New York Dept of Health complaint line; however, the Joint Commission complaint information was not listed. The posters and admission packet information were updated to include the Joint Commission 1-800 number for concerns about the quality of patient care and safety as an option for patients/families to report concerns.
What is the current status?
The new posters have been put up around the hospital and outpatient buildings. Look for the “Be part of your Strong Healthcare Team” posters. The admission packet now contains the updated information and this information was also updated on the Strong Health website on the Patient Rights page.
2. National Patient Safety Goal 8: Accurately and Completely Reconcile Changes in Patient Medications Across the Continuum of Care
- The organization, with the patient’s involvement, creates a complete list of the patient’s current medications at admission/entry for care.
- The medications ordered for, given to, or provided to the patient while under the care of the organization are compared to those on the current medication list. Any discrepancies (omissions, duplications, potential interactions) are resolved.
What did the Joint Commission find during their review?
The Joint Commission surveyors observed two inpatient cases where a complete list of current medications was not obtained upon admission. Surveyors also observed two outpatient cases where the list of current medications was obtained, but there was no documentation to indicate whether new medications ordered were compared to the current home medication list.
Why is this important?
Medication errors often occur when the medications a patient is currently taking at home react badly with medications ordered by the doctor during a patient care experience. Medication reconciliation is the process where the current medications are reviewed and compared to any new medications being ordered to prevent medication errors that could have a harmful effect on the patient.
This is what we are doing about it:
The hospital is currently in the process of updating its computerized medical record to include medication reconciliation. Until the update is completed in 2008, we have developed two new forms to make it easier for medical caregivers to collect medication information and compare it to new medications being ordered. All staff members who are allowed to order medications were given instructions on how to use the new forms. Staff members at our outpatient clinics were given additional education about the correct process for comparing new medications to the current medication list and how to document any changes in medications in the patient’s medical record.
What is the current status?
The hospital and outpatient clinics performed a 4-month review of medication reconciliation from January – April 2008. We did random checks of hospital medical records to look for the presence of a current medication list. Over the 4-month period, the presence of a home medication list improved, showing that 99% of our patients had the list in their records. We also did random checks of the outpatient clinic medical record to see if there was documentation that the current medications were compared to any new medications ordered during the visit. We found that 91% of the outpatient records that were audited had the correct documentation. We are now working with our hospital Pharmacy to improve the quality of our documentation of medication reconciliation and hope to have the computerized documentation system in place by the end of 2008.
3. Provision of Care Treatment and Services 8.10: Pain is Assessed in All Patients
- Healthcare providers regularly reassess a patient’s level of pain and provide follow-up measures as defined by hospital policy.
What did the Joint Commission find during their review?
The Joint Commission observed that pain was not reassessed and documented for all hospital patients within the timeframe established by the hospital.
Why is this important?
Pain assessment is an important tool in monitoring the status of a patient’s condition as well as the effectiveness of treatments being provided. The patient is an important partner in this process. Sometimes, we ask about pain but forget to document the findings. This makes it difficult for future caregivers to know the patients comfort level and make appropriate care decisions and provide the appropriate pain relief measures.
This is what we are doing about it:
Each patient’s level of pain is assessed at regular intervals depending on the extent of the pain and the type of pain relief being provided. This assessment is included in nursing documentation, just like blood pressure and temperature are documented. The inpatient and outpatient pain assessment procedures were reviewed with all nursing staff in December 2007.
What is the current status?
We performed random audits of medical records January – April 2008 to check that pain assessment was performed at the appropriate time and documented. Results showed that pain assessment was done 94% of the time. We will continue to work toward our goal of 100% of patients receiving pain assessments at the appropriate time.
4. National Patient Safety Goal 2: Improve Communication Among Caregivers
- Develop and implement a list of abbreviations that are not to be used in documentation.
What did the Joint Commission find during their review?
The Joint Commission found that we had a list of “Do Not Use” abbreviations that has been communicated to all caregivers. However, in some medical records documentation, they found instances where the abbreviation for “daily” (QD) and the lack of a leading zero in decimal dosage (0.4 mg) were written.
Why is this important?
Some abbreviations can be misread and misunderstood by caregivers. This can lead to errors in the amount of medications or treatments being provided. Studies have shown that misunderstood abbreviations are one of the leading causes of medical errors.
This is what we are doing about it:
Caregivers were given reminders about the need to avoid the abbreviations on the “Do Not Use” abbreviation list. The list of prohibited abbreviations is posted in patient care areas, staff lounges, and is also included on the forms that are used to document care.
What is the current status?
We randomly reviewed medical records for inpatients, emergency department patients, and outpatient clinic patients for the use of unapproved abbreviations in the medical record documentation. The record audits occurred from January – April of 2008 and it was found that 95% of the records reviewed did not contain the prohibited abbreviations. We are continuing to educate all staff about the risk of using these abbreviations including this as part of our orientation program for all new caregivers. Our goal is to completely eliminate the use of these abbreviations. We will continue to randomly audit records for the use of these abbreviations and provide feedback and re-education to staff found using them.
5. Medication Management 2.20: Medications are Properly and Safely Stored
- Medications are stored under conditions suitable to maintain product stability.
- Unauthorized persons cannot obtain access to medications.
What did the Joint Commission find during their review?
The Joint Commission found two areas where they were unable to determine if medications were stored under proper conditions:
- In one of our operating rooms, surveyors found IV fluid bags in the IV fluid warmer that had not been dated when they were placed in the warmer. IV fluid bags must be dated when placed in the warmers as the temperature change will effect how long the IV fluid is still safe to use.
- In one of our outpatient sites, the Joint Commission found that there was a refrigerator used to store medications that did not have the correct type of thermometer in it to record that the refrigerator temperature stays in the appropriate range for medication storage even when the clinic is closed.
The Joint Commission found three instances where unauthorized staff might be able to access medications:
- There were two nurses who were no longer employees of the hospital but the Pharmacy records showed that the hospital had not yet terminated their access to the medication dispensing machines.
- On our post-partum nursing unit patients are allowed to have a supply of over the counter pain medications which they can take as needed. These medications were found on the bedside table which poses a potential risk of other people being able to take the medications without approval.
- On the Pediatric Intensive Care Unit two medication refrigerators that could not be locked were located in the hallways where staff could not monitor access continuously.
Why is this important?
Medications that are stored under improper conditions can lose their effectiveness and possibly become dangerous. It is important to maintain careful control over the storage conditions to prevent this from occurring and causing harm to our patients. Access to medications must also be strictly controlled to prevent improper administration of medications to patients by staff, family or visitors who do not have the authority or training to do so. This could lead to incorrect medications being given to patients with serious medical consequences.
This is what we are doing about it:
IV Fluid in Warmers—A new policy was created that specified the appropriate method for labeling and dating IV fluid bags placed in warmers. This was communicated to all patient care areas. We check the warmers each day to make sure bags are dated properly and remove any that have expired.
Refrigerator Thermometers—We checked all our medication refrigerator thermometers and replaced those that were the incorrect type for tracking high and low temperatures when the clinic is closed. We check all the refrigerator temperatures (high and low) each day to make sure the temperatures stay in the appropriate range and keep a log of these temperatures.
Unauthorized access—A new procedure was developed to notify pharmacy when staff with medication dispensing machine access leaves the organization. Pharmacy immediately removes their ability to access these machines. The post partum unit no longer allows patients to take over the counter medications on their own. These medications are given by nursing staff. We placed keyed locks on the refrigerators in the Pediatric ICU with access to the keys controlled by the Nurse Manager of the unit.
What is the current status?
Logs for the refrigerator temperatures and dating of bags in warmers were reviewed randomly from January – April of 2008. This review showed that these were monitored appropriately 100% of the time. We continue to monitor access to our medication dispensing machines to assure that staff no longer employed by the organization has their access removed. When installing new medication refrigerators we make sure they are installed in areas that are supervised by staff 100% of the time or have locks preventing unauthorized access. The staff on our postpartum unit is investigating options for safe storage of over-the-counter medications in the patient room so that patients who prefer to take these medications on their own do not need to rely on nursing staff to obtain and administer the medication.
6. Human Resources 1.20: Staff Qualifications are Appropriate for the Job Responsibilities
- The organization verifies that staff licensure, certification or registration is up-to-date.
What did the Joint Commission find during their review?
During a review of staff files, the Joint Commission found that one physical therapist did not have documentation on file showing that his or her license had been renewed.
Why is this important?
Some staff with specific training requirements needs to pass licensing exams to indicate they are qualified to perform specialized patient care activities. There are often ongoing education requirements to maintain this licensure. The organization needs to be sure that all licensed staff has the necessary education and training to provide services safely to our patients. It is the responsibility of the organization to make sure that staff is licensed appropriately.
This is what we are doing about it:
The licensure of the physical therapist was verified immediately and it was found that the license was up-to-date but not documented in the staff file. A new process for verifying licensure was developed and communicated to all managers. The license of all new staff will be verified upon hire and the staff person’s manager will be notified of the expiration date. The managers will verify and document that licenses are renewed on time.
What is the current status?
All staff files were reviewed to confirm that licensure was appropriately renewed. A centralized approach for monitoring license renewal is being investigated.
7. Leadership 3.90: The Leaders of the Organization Develop and Implement Policies and Procedures for Care, Treatment, and Services
- Policies and procedures are consistently implemented.
What did the Joint Commission find during their review?
The Joint Commission found three instances where policies were not consistently followed by staff:
- Hospital policy requires that whenever a procedure occurs on a specific side of the body, the correct side needs to be indicated and the site needs to be marked. The Joint Commission surveyor found that during a procedure where a chest tube was inserted at the bedside, the documentation for the procedure did not indicate which side the tube was inserted and that the site was marked.
- Hospital policy requires monitoring vital signs at specified intervals when giving patients blood transfusions. The Joint Commission surveyor noted that the vital signs were not being consistently recorded during transfusions on one of our nursing units.
- Hospital policy requires that prior to a surgical procedure, staff takes a “time out” or pause to verify the type of procedure to be done and the correct body site before proceeding. All staff that participates in this time out should be identified and their names recorded in the medical record. The Joint Commission surveyor found in reviewing documentation for an outpatient surgical procedure, that the name of a resident who participated in the time out was not recorded in the medical record.
Why is this important?
It’s important to have policies for providing patient care so that all caregivers are aware of the expectations and care is provided in a consistent manner. Having a policy is the first step. Making sure that staff follows the policy is the second step to ensure safe, high quality care is being provided. Leaders of the organization have a responsibility to monitor that policies are being followed consistently to avoid harm to our patients and ensure that they receive consistent, high quality care.
This is what we are doing about it:
Our medical and nursing leadership re-educated staff on the appropriate policies relating to documentation of procedures where the side needs to be indicated, monitoring of vital signs during blood transfusions, and documenting all participants in the time out process for surgical procedures. For chest tube side documentation, we reviewed our current forms and made changes to clearly communicate that the appropriate side needed to be indicated and marked for the procedure. For blood transfusion vital signs the procedure for documenting vital signs at appropriate intervals was reviewed with all nursing staff. For documentation of time out participants, our procedure forms were modified to include additional space for recording the names of all participants.
What is the current status?
We performed random audits of medical records from January – April of 2008. We checked for correct documentation for all three procedures and found that these were correctly documented 92% of the time. We are not satisfied with this number and will continue to monitor our consistency with following these policies. We will identify staff members who fail to document these procedures according to our policies and provide additional education.
8. Environment of Care 5.20: The Environment Meets all Life Safety Code Fire Safety Requirements
What did the Joint Commission find during its review?
The Joint Commission found that our facilities were designed and maintained for the safety of our patients for the most part. They did find the following areas for improvement:
- Some floors and ceilings needed updated fire resistant material.
- A fire exit door had a broken latch.
- Some double doors did not latch appropriately.
- Some doors had a gap greater than 1/8 inch, which doesn’t meet fire code.
- A security desk in a hall of the Emergency Dept was not enclosed by fire-safe partitions.
- A waiting room was not equipped with a smoke detector.
- Some storage rooms were not smoke tight.
Why is this important?
The Life Safety Code has strict standards for fire safety that are for the protection of all our patients and staff. Adherence to the standards is mandatory to continue providing care to the public.
This is what we are doing about it:
All the problems with door latches and gaps were fixed to comply with fire safety requirements. Storage rooms were made air tight. A smoke detector was installed in the waiting room. The security desk in the Emergency Dept was moved out of the hall to a new location to comply with fire codes.
What is the current status?
Staff from our Facilities and Fire Safety departments conducts regular walking tours of all our facilities to make sure that safety violations are identified and acted upon. Work orders are generated to fix any problems that can be quickly corrected. Larger repairs are documented and a corrective plan developed, including a time frame, which is sent to the Joint Commission. We are required to follow this plan or be able to explain to the Joint Commission why we are not able to correct the problem within our established time frame.
