Surveyors focus on disaster planning, medication safety
Surveyors focus on disaster planning, medication safety
During a recent Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey at Baylor All Saints Medical Center in Fort Worth, TX, surveyors walked into the ED's main entrance and saw every bed full, with nurses moving patients to nonmonitored beds to free up monitored beds for other patients.
"They did not want to speak with the charge nurse because it could interrupt patient flow," says Susie Hood, RN, administrative director of the ED. "Once the JCAHO team saw how busy we were, they spoke to me."
The physician surveyor asked how "look-alike, sound-alike" medications were handled. She showed him that the pharmacy had posted a list of those drugs on the front of the automated medication dispenser. "He then asked to see how I accessed them," says Hood. "This gave me the opportunity to demonstrate that dopamine and dobutamine were in completely separate drawers."
Next, the physician surveyor checked rooms and bedside tables for any unsecured medications. "He also observed to see if staff were doing patient identification and following hand-washing procedures," she says. "The majority of ED rooms are curtained "bays," making it particularly challenging to wash hands before you leave the bedside." Surveyors observed staff going to the nearest hand sanitizer station or sink as soon as they left a patient's bedside and before they went to the next patient's bedside.
During a patient tracer on a stroke patient, the physician surveyor was concerned because he saw an order on an inpatient unit stating "OK to do MRI in AM." "He did not understand that MRI was not the front line diagnostic testing for acute stroke," Hood says. "A CT is the front line diagnostic testing for acute stroke, meaning that we had followed our protocol as AHA [American Heart Association] guidelines state."
Disaster planning was another focus. "But surveyors also realized that everyone is trying to prepare for a host of scenarios. They were more lenient here," she says. The surveyors asked how and where patients would be decontaminated, and where emergency preparedness equipment was stored.
The surveyors were concerned about the accessibility of emergency preparedness supplies such as a decontamination tent, biohazard suits, respirators, and triage disaster tags, because these items required elevator travel to move them to the ED. "We quickly relocated the equipment and sent the surveyor a note that it had been moved to the same level floor as the ED, and they were happy," says Hood.
Surveyors asked how patients could access the ED or the building in general if there was a contamination situation. "We told them no, patients would not access the building," she says. "We then explained how and where we would put up our portable decontamination tent."
To prepare nurses for survey, a team of volunteers developed games such as Family Feud and Jeopardy to play at each staff meeting. "We surveyed our nurses and gave prizes such as clocks and gift certificates for the most correct answers," says Candace Duran, RN, an ED nurse who participated in preparation for the Joint Commission survey.
"We also randomly went around and asked staff questions about JCAHO requirements," she adds. "Our manager also came around and quizzed us."
The Joint Commission surveyors commented about the overall courtesy and receptiveness of the ED staff. "As the surveyors came into our unit, they noted that staff greeted them and were ready to respond to their questions," says Hood.
Sources
For more information about the accreditation survey, contact:
- Candace Duran, RN, Emergency Department,Baylor All Saints Medical Center at Fort Worth, 1400 Eighth Ave., Fort Worth, TX 76104. Telephone: (817) 922-7070. E-mail: [email protected].
- Susie Hood, RN, Administrative Director, Emergency Department,Baylor All Saints Medical Center at Fort Worth, 1400 Eighth Ave., Fort Worth, TX 76104. Telephone: (817) 922-1158. E-mail: [email protected].
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