Page 5 - Fall 2019 Castle MD

Joint Commission Survey – Excellent
Results!
Congratulations to the medical staff
for another excellent Joint Commission Survey! Medical staff at hospitals across the nation have struggled with a variety of issues, but our physicians had zero findings for the following highly scored items:
• Infection Prevention: Inadequate
hand hygiene or improper use of personal protective equipment (PPE). Forgetting to remove PPE if it becomes contaminated or before leaving a patient’s room. Not covering all hair or facial hair in the OR.
• Therapeutic duplication of orders: Especially common with nausea
and vomiting medications without differentiating instructions, and pain medications that have overlapping pain scales.
• Consents: Not signed or timed.
• Time outs: Not pausing and paying attention or not actively participating with an audible response.
• Medication security: Unlocked anesthesia carts between cases, unlocked anesthesia workrooms, unlabeled syringes or labels missing required elements (name, strength, quantity, diluent and volume, expiration date and/or time).
The surveyors emphasized our exceptional wins, including zero findings for any National Patient Safety Goals. These
goals include timely reporting of critical test results, CLABSI prevention, CAUTI prevention, C-diff prevention, suicide prevention, preventing transfusion
errors, preventing harm associated with anticoagulation therapy, preventing surgical site infections and preventing wrong site/ wrong patient surgeries. It is very unusual for a hospital not to get sited on any of these National Patient Safety goals.
Castle did receive two findings directly related to physician practice. One was regarding an H&P that was not completed within 24 hours of admission, and the other was a Pitocin order that did not stipulate objective parameters to determine adequate contractions or maximum dose.
Neither of these findings, however, were high-risk or widespread, which is exactly how we like to find errors when they occur. We know that the probability of a sentinel event is directly proportional to day-to- day deficiencies. The more deficiencies an organization is willing to live with and not correct, the greater the risk of harm to its patients or workforce. That is why we like to catch problems while they are still small and limited in scope.
In addition to our safety culture and commitment to “chase zero harm”,
the surveyors also recognized our compassionate work culture and expressed that they actually “had fun at work” during our survey. We hope you experience the same when you work at Castle.
FALL ‘19 · 5