Accreditation

Greeley Reflections

Accreditation Connection, February 8, 2010

Risk assessments for unclear standards

Part 4 of 4

Continuing from last week, let's review the rest of the blanket warmer sample.

Section 5—Operations: There is an acknowledgment that temperature monitoring is difficult to implement and is typically not successful. Better are processes that build in a margin of safety for the patient.

Section 6—Conclusion/Position: This fictitious institution decided not to set a maximum temperature for blanket warmers but, instead, to reinforce preventive maintenance. It also decided to prohibit the storage of intravenous fluids in blanket warmers.

Section 7—Approvals: This institution had the position approved by the PI Committee, the Operating Room Committee and the Leadership Council. You can choose the right level of approval for the issue and your organization.

So now just put the analysis in a place where you can find it and you’re set. You don’t have to reassess unless something changes (e.g., a regulation, the literature, incidents, and so forth).

We are comfortable that the approach recommended, assuming the conclusion is consistent with the data in the assessment, will ultimately hold sway over surveyor preference.

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