BWH Responds to Joint Commission Survey
The Joint Commission survey team based its review of BWH procedures on 265 performance standards, and of these, the team identified nine Requirements for Improvement (RFIs).
Critical Test Results
This focuses on the time required to get test results from the lab to the patient’s nurse and doctor. The Joint Commission found that BWH was not consistently documenting the time it took to get the test result to the doctor.
Following the Joint Commission survey, BWH’s Quality Improvement Team assessed the process for responding to and documenting abnormal critical test results. The new process calls for physicians to be paged when crtical lab test results are available and for physicians to read back the results to the person who paged them.
Pharmacy Review
The Joint Commission found that in a small minority of cases, Pharmacy had not reviewed a doctor’s medication order before the medication was given to a patient.
BWH has implemented a plan where drug orders are reviewed by Pharmacy. This ensures safety for all patients.
Labeling Medications
This category involves removing a product such as a medication or solution from its original container and placing into another, possibly smaller container such as a basin or syringe. To ensure patient safety, once the product is removed from the original container and put in another container, that second container must be labeled immediately after the removal of the medication or solution.
BWH has developed an education program to reinforce this policy with all care providers, and the hospital will monitor these efforts.
Medication Reconciliation
This category involves comparing patients’ home medications with medications that they receive in the hospital to avoid any potential negative drug-drug interactions and make sure correct doses and medications are prescribed, especially when the patient is discharged from the hospital.
BWH is developing a computer program that will help doctors, nurses and pharmacists compare any drugs a patient may be taking at home with those the patient may receive at the time of hospital admission and discharge. Until the computer program is finalized a manual review process is in place.
Use of Restraints
Restraints are sometimes used to protect patients who may be agitated or need protection from unintended movements while they are in the hospital. This RFI reflects the need for more timely documentation by the treatment team when restraints are in use.
BWH has developed a bedside reference sheet for the treatment that outlines the restraint policy and documentation requirements.
Access to Gas Shut-off Valves
This category focuses on clear access to these valves, and the RFI notes equipment was located under some of these valves.
BWH has moved equipment from under the valves; and is continually monitoring equipment storage.
Clutter
This is a challenge for most hospitals. As new technology is introduced to the care process, it takes up space. The Tower, built more than 25 years ago, faces the challenge of finding room for the new technology. The opening of the Carl J. and Ruth Shapiro Cardiovascular Center will create some new space for our technology-based patient safety initiatives.
Environmental Services created a program to identify equipment that is no longer needed on a daily basis and remove it to a storage area in order to create space. The initial phase of this program removed 10 tons of metal and 2,412 pounds of unusable computers.
Fire Exits
This category focuses on the need for clear signage for all fire exits, and all fire exits now have signs that are clearly visible.
Fire Pump Testing
The category focuses on testing our fire pump weekly, and BWH now is testing the fire pumps weekly.