North Fulton Regional Hospital – Roswell, GA (March 12, 2009) – Medication is a standard element of the healthcare delivery system. It is imperative that a patient reveal all medications he or she takes, including dosage information, upon admission to the hospital. Physicians and nurses must then manage and track these medications to foster safe administration. Cardiac Rehabilitation Nurse Susan Tassitano has dedicated the last year and a half of her time at North Fulton Regional Hospital to serve as an intermediary in the reporting process, helping to ensure that all medication information is accurate.
According to Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) policies, hospitals are required to send all patients away with a home medication list. This list should correlate with the patient’s Medical Administration Record (MAR) that the hospital keeps on file. Tassitano discovered that on some occasions, discrepancies existed between these two forms.
“Sometimes the patient’s sheet would be missing a medication that was listed on the MAR, but there would be no explanation on the physician order sheet noting that the particular medication had been discontinued,” Tassitano said. “So I was left to wonder, did the nurse who filled out the patient’s medication sheet make a mistake by leaving it off? Or, did the doctor simply forget to write ‘discontinue upon discharge’ on the hospital’s patient record?”
To monitor this reporting process, Tassitano audited 50 patient charts from various departments each month from January 2008 to October 2008, comparing the medication list that the patients would take home against the hospital’s patient records. After her audit, she then sent the results back to the department nursing directors for proper follow-up.
This performance improvement project has yielded successful results as the percentage of accurately completed medication reports has increased by almost 25%. In addition, each department has embraced the initiative, designating one nurse on each unit as the official auditor of patient medication records.
“Now that the departments are auditing their own charts, improvements in the process can be made more efficiently. This also gives more of our nurses the opportunity to complete performance improvement projects on their units,” Tassitano explained.
North Fulton Regional Hospital offers its nurses opportunities to participate in performance improvement initiatives that not only help them on a professional level but also help enhance quality at the hospital. Tassitano’s medication reporting project was one such initiative that spawned many other smaller projects throughout the various departments.
“This project involved a change in our process to help ensure the safety of our patients, which is our primary goal.” Now with the inpatient report auditing off of her plate, Tassitano is moving on to the outpatient services reports. 2009 looks to be yet another busy year for the dedicated nurse.
North Fulton Regional Hospital (NFRH), part of Tenet Georgia, is a 202-bed, acute-care
hospital located on Highway 9, Alpharetta Highway, in Roswell. Opened in 1983, NFRH serves North Fulton and surrounding counties through its team of over 1000 employees, 400 staff physicians and 200 volunteers. NFRH is a state-designated Level II trauma center and provides a continuum of services through its centers and programs, including neurosciences, orthopedics, rehabilitation, surgical services, bariatric surgical weight loss, gastroenterology and oncology. The hospital is fully accredited and also is certified as a Primary Stroke Center by the Joint Commission on the Accreditation of Healthcare Organizations, the nation’s oldest and largest hospital accreditation agency.
For more information about North Fulton Regional Hospital’s commitment to quality and performance improvement, please visit www.northfultonregional.com/quality, or call 770-751-2500.
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