Accreditation Audit AFT 2 Task 3 Patient Care Improvement 1
Task 3 Patient Care Improvement
Western Governors University
Accreditation Audit AFT 2
Accreditation Audit AFT 2 Task 3 Patient Care Improvement 2
Evaluation
The tracer patient is a 67-year-old female who presented to the Nightingale Community
Hospital Ambulatory Surgical Unit for a laparoscopic hysterectomy. Due to excessive bleeding
during the laparoscopic procedure, the surgeon converted to an open procedure. The patient
returned to the hospital five weeks after discharge from the procedure due to a suspected
postoperative infection; symptoms included fever and drainage. The patient had surgery five
days after admission to remove an abscess that formed from the initial surgery that occurred five
, weeks ago. During the abscess removal, it was determined that a central line was required for
long-term antibiotics. The patient was discharged with home health care instructions to manage
antibiotic therapy.
A tracer round determined that staff did not complete a medical history and physical
examination within 24 hours of the patient’s admission. These events occurred more than 72
hours before admission to the hospital, putting the hospital out of compliance. Failure to
complete a medical history and physical examination within 24 hours violates the Joint
Commission standard PC 01.02.03, EP4. Per the Elements of Performance (EP) for PC 01.02.02,
medical history and physical examination is to take place no more than 30 days before, or within
24 hours after, registration or inpatient admission but before surgery or a procedure requiring
anesthesia services (The Joint Commission, 2022).
Action Plan
Task 3 Patient Care Improvement
Western Governors University
Accreditation Audit AFT 2
Accreditation Audit AFT 2 Task 3 Patient Care Improvement 2
Evaluation
The tracer patient is a 67-year-old female who presented to the Nightingale Community
Hospital Ambulatory Surgical Unit for a laparoscopic hysterectomy. Due to excessive bleeding
during the laparoscopic procedure, the surgeon converted to an open procedure. The patient
returned to the hospital five weeks after discharge from the procedure due to a suspected
postoperative infection; symptoms included fever and drainage. The patient had surgery five
days after admission to remove an abscess that formed from the initial surgery that occurred five
, weeks ago. During the abscess removal, it was determined that a central line was required for
long-term antibiotics. The patient was discharged with home health care instructions to manage
antibiotic therapy.
A tracer round determined that staff did not complete a medical history and physical
examination within 24 hours of the patient’s admission. These events occurred more than 72
hours before admission to the hospital, putting the hospital out of compliance. Failure to
complete a medical history and physical examination within 24 hours violates the Joint
Commission standard PC 01.02.03, EP4. Per the Elements of Performance (EP) for PC 01.02.02,
medical history and physical examination is to take place no more than 30 days before, or within
24 hours after, registration or inpatient admission but before surgery or a procedure requiring
anesthesia services (The Joint Commission, 2022).
Action Plan
