Accreditation Audit: Assuring the Transfer of Accurate Patient Information

Paper Type:  Research paper
Pages:  6
Wordcount:  1432 Words
Date:  2022-05-17


It is vital for hospitals to maintain an excellent accreditation standing to continue serving the community. The accreditation audit will demonstrate how the Nightingale Community Hospital has complied with the communication standards based on their site identification and verification policy. The hospital uses the site identification and verification protocol as well as pre-procedure handoff forms to make sure that site, procedures, and handling of the patient are successful during surgery. A pre-procedure handoff is a form that entails a checklist that helps the medical staff on a handoff to accept patients before a procedure. The report seeks to determine if the hospital's approach to patient hand-off, procedure and site are in line with the requirement of the Joint Commission. The report will finalize with a recommendation for maintaining communication standards in the hospital.

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Compliance Status

Nightingale Community Hospital has site identification and verification protocol that highlights the process of verification before operation or procedure, the process of verifying the site as well as the process of marking the site. The initial part of the protocol depicts the significance of communication in determining the success of the procedure. According to Michael, Della, and Huaqiong (2013), the safety of the patient is at risk in instances of failed communication. Michael, Della, and Huaqiong (2013) point out that unclear order over the phone, lack of critical information, and misinterpretation of the information are mostly overlooked in the hospital setting. The existing gaps in the current protocol have added to nurses' misinformation about the process of screening at the hospital. First, the policy has failed to mention the pre-procedure hand-off. Although the protocol mentioned that correct site, procedure and person will happen, it fails to outline how the verification should be fulfilled and how it will be used. Second, the policy states that the failure to mark the site should be indicated in the pre-operation checklist. However, the policy does not have an attachment of the checklist for references. The standard UP.01.01.01 of the Hospital National Patient Safety Goals (2015) demands the verification of the correct placement of the patient's body. Although the protocol outlines the use of abbreviations LT for left and RT for the right, these abbreviations appear the same when not written clearly and should be spelled out rather than using abbreviations to avoid likely errors. Third, although the policy mentions that the staff should verify the site and procedure with patients, it fails to demonstrate how the verification should be accomplished. Specifically, the document does not show how the placement of permanent black market is an indication that the correct side should be done correctly. Besides, the use of right and left need to be spelled rather than the use of abbreviations. Fourth, the protocol outlines that all the people involved in the procedure should verbally and audibly perform the time-out. However, the policy does not highlight time-out documentation or time-out pre-determination. Finally, the document does not need site marking when the person carrying the procedure is in continuous interaction with the patients. Since Nightingale Community Hospital considers this to be universal policy, it should implement it to all procedures for safety and minimize staff confusion over the process.

Nightingale Community Hospital depicts pre-procedure hand-off checklist as a form that has a checklist to enable the staff from hand-off to accept patients before a procedure. The form is designed in a yes/no checklist with an allowance to explain a few items such as medication and the primary language. Although the form is detailed, it lacks several key items which makes it a challenge for the staff to demonstrate the expectations of the process. The Hospital National Safety Goals (2015) demands at least two patient identifiers to affirm the correct patient. The current hand-off form does not highlight two identifiers, not the kind of identification to be attained. Besides, the form does not list the verification for which the patient would undergo. Furthermore, the hand-off checklist fails to highlight the physician and the procedure location. Although the form indicates the nurses responsible for the handoff and patient reception, it does not indicate the other part to review the form to ensure that the screening is communicated. Besides, there is no indication of what should be done with the hand-off checklist once completed.

Plan for Compliance

The following is a list of recommendation based on the areas of communication that Nightingale Community Hospital needs to consider based on the items discovered in the audit report.

The revision of the pre-procedure hand-off checklist should include:

  • Two patient identifiers documented and specified
  • Lines included in each review area for documentation
  • A clear highlight of the site
  • Pre-determines area for a patient identification sticker
  • The surgery or procedure listed on
  • The site of the procedure and the physician performing the procedure
  • A witness nurse to sign off on nurse review
  • The checklist to stay with the patient chart as part of the medical record

The revision of the site identification and verification protocol should entail:

  • Two patient identifiers documented for verification process can be included in the pre-operation checklist
  • The site and procedure should be highlighted and included in the pre-operation checklist. The pre-operation checklist attached to the policy for references.
  • The pre-procedural handoff checklist should have all the invasive surgeries and procedures with a revised form attached to the policy.
  • Although the timeout procedures can happen verbally and audibly, it should have documentation of time-out in the patient's medical record for accuracy and consistency.
  • The nurse verification site and procedure with patients should have demonstrated patient's sign of the correct site.
  • The hospital staff should sign an attestation affirming their understanding of the process and opportunities for questions.
  • Training through education should be rolled out to the hospital staff on revised process and forms.
  • Random audits should be developed weekly during the first three months of rollouts for accuracy and validation. The Fallouts should be discussed with the involved stakeholders.


Pre-procedure handoff is a critical process which the staff conveys relevant health information before a procedure. During this process, the nurse needs to communicate critical information related to site, patient, and procedure properly. Barry (2014) demonstrates communication as the exchange of accurate and pertinent health information which is essential to attaining quality care. Therefore handoff communication is the effective exchange of patient health information which demonstrates accountability acceptance and transfer from one nurse to the other. The version of handoff entails sharing of critical patient information with the intent of continual care. Holly and Poletick (2013) believe that communication during the handoff process is significant for continuity of care as well as the safety of the patient. However, the process is fraught with errors and high potential to compromise patient outcomes and safety. The Joint Commission (n.d) reported that nearly 75% of the sentinel events in the hospital could be liked to communication breakdown. According to Michael, Della, and Huaqiong (2013), the safety of the patient is at risk in instances of failed communication. Michael, Della, and Huaqiong (2013) point out that unclear order over the phone, lack of critical information, and misinterpretation of the information are mostly overlooked in the hospital setting. Therefore, ensuring effective communication will allow Nightingale Community Hospital to ensure patient safety, team and patient satisfaction and limited risks related to malpractice (Noguchi, 2014). Nightingale Community Hospital has developed site identification and verification protocol as well as pre-procedure handoff forms that facilitate a predictable guideline for organizing critical, concise and relevant patient information among the hospital staff. Regardless, these tools appear to be a threat to patient safety which calls for the development of revised tools.


All in all, the objective of the Joint Commission is to ensure that healthcare institutions achieve quality health care based on the set standards. The comparison between the set standards and Nightingale Community Hospital's policies calls for the hospital to review, evaluate and develop some adjustment to the current communication policies. The hospital can determine what needs improvement by performing routine audits of workflow processes.


Barry, M. (2014). Hand-off communication: Assuring the transfer of accurate patient information. American Nurse Today, 9(1), 30-31

Holly, C., & Poletick, E. (2013). A systematic review of the transfer of information during nurse transitions in care. Journal of Clinical Nursing, 23, 2387-2396.

Hospital National Patient Safety Goals. (2015). Retrieved from

Michael, R., Della, P., & Huaqiong, Z. (2013). The effectiveness of the Surgical Safety Checklist as a means of communication in the operating room. ACORN: The Journal of Perioperative Nursing in Australia, 26(2), 48-52

The Joint Commission. (n.d.). Retrieved from

Cite this page

Accreditation Audit: Assuring the Transfer of Accurate Patient Information. (2022, May 17). Retrieved from

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