Accreditation

Verbal orders and proper equipment were the focus of two recent surveys

Accreditation Connection, July 9, 2004

Documentation came under the microscope during two recent surveys by the JCAHO. At one hospital, surveyors wanted staff to document any problems that they had with medical equipment. At another, they examined how well the hospital complies with its own policy to document all read-backs of verbal orders and critical test results.

Medical equipment reviews

Wayne Memorial Hospital in Honesdale, PA, scored a 98 during its November 2003 survey-and received compliments from surveyors for its high score.

However, surveyors also said the 92-bed hospital needed to keep better tabs on how well staff understand the medical equipment they work with.

Specifically, the surveyors want the hospital to document any user errors or near-misses that staff have with equipment such as cardiac monitors or patient-controlled analgesia (PCA) pumps.

"They want us to keep track of it so that we can pick up on trends with certain pieces of equipment, such as whether it's always the same equipment, person, or nursing unit that has problems," says Cinda Tietjen, RN, BSN, the hospitals' performance improvement manager and JCAHO coordinator.

The surveyors also suggested that unit managers identify staff who need extra training on certain pieces of equipment and to make sure they receive it.

Solution: Surveyors suggested that department managers review the medical equipment on their respective units each year with a biomedical staffer to determine whether staff require additional education.

Reminder: It's important that nurses and other staff understand how to use PCA infusion pumps, since JCAHO's National Patient Safety Goal #5 requires them to ensure that all general-use and PCA pumps have free-flow protection.

In addition, Goal #6 requires hospitals to perform routine preventive maintenance and testing on all clinical alarms.

Verbal order read-backs

Pella (IA) Regional Health Center wanted to go above and beyond the read-back requirement of JCAHO's second National Patient Safety Goal, which requires organizations to develop a process for verifying orders or critical test results that are received verbally/over the telephone.

Although the goal doesn't require hospitals to document the read-back verification, the rural hospital decided to write this requirement directly into its policies and procedures.

Problem: Staff did not consistently document their read-back verification. In addition, the hospital could only demonstrate six months of documentation compliance with the goal; surveyors during the November 2003 survey wanted to see a 12-month track record, says Barb Braafhart, RN, risk manager and privacy officer.

Solution: Unit nurse managers audit 10% of their orders each month. If 90% of them do not include a quick notation indicating who verified the verbal order or test result, the manager must provide education for all unit staff.

In addition, the manager must intensify the monthly audit by examining 50% of all orders. This continues each month until 90% of the orders include documentation of read-back verification, Braafhart says.

Most units already have a 90%-95% compliance rate. Problem units with lower compliance rates include the hospital's outpatient clinic, which is well below the target rate, says Braafhart.

"They're not used to doing this kind of documentation," she says. "Their volume of verbal orders is huge and to always remember to write down [the verbal order read-back] is difficult."

Solution: More education for clinic staff and monthly chart audits to assess their compliance.

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