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One of these checks recently preformed was of a 67 year old patient who presented for a hysterectomy. She ended up with complications and subsequent treatment for these complications, all care was provided by Nightingale Community Hospital. Mistakes were made with this patients care and corrective actions will be taken. We will write a custom essay sample on Arts or any similar topic only for you Order Now It is cases like these we strive to correct, in order to become â€Å"the hospital of choice for patients, employees, physicians, volunteers, and the community. † (Nightingale Community Hospital, p. ) In order to learn and grow from the mistakes made with our tracer patient, we must identify specific mistakes made and develop a corrective action plan to address the improvements we are going to make. According to the information provided by our tracer patient’s worksheet, it was determined the patient presented for â€Å"librarianship hysterectomy that was converted to an open procedure due to excessive bleeding approximately five weeks prior to hospitalizing. † After examining our patient’s worksheet, or fact sheet, a few items throughout their care with us was not up to standards. First mistake found was our tracer patient did not have an admissions assessment thin the 24-hour window, starting with the time of admissions. The tracer patient’s physical was done over 72 hours after admission. Second, the staff reported completing a functional assessment but there was no documentation supporting this claim in her chart. Third, the nurse evaluated the need for an advance directive, found none to be present, and requested the family bring one with them. The family never followed through and did not provide it. Fourth, the nurses did not update the tracer patient’s plan of care since the surgery, and this assessment was done 5 weeks after surgery upon re-admittance. Fifth, a pain assessment is supposed to be done within an hour after pain medications are given. The night before this assessment, the follow up was done over an hour after the pain medication was distributed 4 times. Sixth, the tracer patient’s oxygen tanks were not secured properly and her room’s air vents were dirty. Seventh, the nurse was not able to explain range order or give a proper range in milliards. Eighth, hand off communication is poor when patient transfers units and or providers. The SD, OR nurse and PACIFIC nurses employed all evaluation tasks properly. As you can see, many steps required for safety were either incomplete or overlooked. In order to bring this tracer patient up to the standards of the Joint commission a corrective action plan needs to be made. For this assessment I am going to concentrate on the issues of medication range orders and communication during the hand off process. Medication range orders are very important because they can prevent over fusing and under dosing. Over dosing has obvious consequences or poisoning and even death, under dosing can lead to the patient Ewing in unnecessary pain. The hand – off process is very important and was addressed in prior assessments. This is where most mistakes within a hospital take place. A hand-off can include when a patient goes from one department from another or even when there is Just a shift change. In our previous case, the disorientation or the hand off lead to one of Nightingale Community Hospital’s patient’s Tina, to be discharged to a parent who did not have custody of her, resulting in a sentinel event. 2. 1 . Nightingale Community Hospital needs to repeat the steps taken to evaluate the racer patient on a wider range of patients. They need to re-evaluate the care of at least 100 patients receiving general anesthesia and inpatient surgery within the last 60 days. This is an important step to take to make sure these mistakes were not made as an isolated incident and more as an over all hospital wide issue. Assuming these mistakes are typical to Nightingale Community Hospital, it should proceed with the following steps. 2. Nightingale Community Hospital will concentrate on two specific failures: medication range orders and communication during hand off process. These areas need to be a priority because they have the greatest consequences. Poor communication leads to almost all patient issues and medication dosage can quickly lead to fatalities. . In regards to hand offs and transferring, the Joint commission requires â€Å"The hospital’s process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information. Note: Such information may include the patient’s condition, care, treatment, medications, services, and any recent or anticipated changes to any of these. Anoint C ommission, 2014, p. 1) As described in the tracer patients information, the hand-off preformed was â€Å"Disjointed hand-off process, inconsistent use of handcuff form. To correct this staff, specifically all nurses and transport staff, will be re-trained how to transfer patients. Executives and unit super visors will collaborate on making a check off list, including such items as patient condition review, care treatment, medications and services (as recommended by the Joint Commission), which the two providers who are handing off the patient will both initial and review. . After the executives and unit supervisors develop the check off lists for all departments, an online training session will be mandatory for all employees. It will followed with a brief in person review of all employees by their unit super visors within 30 days of the implementation and the results will be kept in all employee files. The people responsible for this issues are the nurses and the transport staff. A measure of success is going to be a check off list, which has specific questions both the send off person and the receiving staff will have to fill out. Both of the questionnaires will be filed in the patients chart and their will be a set for each hand off the patient encores throughout the day. The question air protocol will start in two weeks from today. This will go on for one week throughout the entire hospital. Each of the lead super visors for each division or floor will then compile these questionnaires, compile a report for each staff member and review the findings with the staff member within 20 days following the one week assessment. They will discuss what can be improved generally and what the employee needs to specifically irking, if anything. C. Similar actions will be taken for range order re-training. Range orders are â€Å"medications in which the medication does may vary over a prescribed range, depending on the patient status. † (, 2009, p. 2) The important of training for range orders is clear. If over dosed, a patient can be killed, and if under dosed, the patient is in pain. Again, the executives and department super visors will collaborate to create range order guidelines and a re-training program. Rather then having this training be an all staff and employee requirement, range order training ill only be implemented with employees who distribute medications. Training should spread further then physicians and nurses, but also to Urn’s aids and certified nursing staff. It is important for them to have this basic training, even through they are not changing the distribution amounts, but they will be better able to spot a mistake if they have further training. The people responsible for this action are all staff members who distribute the medications. The measurement of success is going to be an audit, done by the nursing lead for the day. The lead will audit all charts for he last two hours of each persons shift. The staff will not be informed of this audit. The lead will look over any medications passed to the patient. Calculate what the text book dosage range is, make sure what was given to the patient was within this range. The lead will have on week from tomorrow to start these audits. They will go on for one 24 hours period throughout the hospital. The leads will have one week to compile the data, and one week following to have the reviews with the staff. During the review and nurse will distribute a pamphlet overgrowing orange order dosing. 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