The recent week-long Joint Commission Survey went very well with a few opportunities for improvement identified that concern the Medical Staff areas. Signing medication orders within 48 hours, as well as signing and dating orders continue to be an issue. Pre-labeling of syringes that weren’t yet filled was a concern, and well as the need for more complete labeling of filled syringes. Post-procedure notes are required in the GI and Bronchoscopy Lab, and the form will be instituted that is used in other areas of the hospital.
Overall the results were very positive, and the surveyors extremely complimentary of our processes and team work. Thanks to all who participated, and especially to those who performed the “perfect” time-out with the surveyors watching!