Risk Management Implementation And The Regulatory Environment

Topic 1 DQ 1

I currently work at a hospital that went through Joint commission and unfortunately had couple of big findings in our Operating Rooms at Little Company of Mary Hospital. One of the main focuses was that most of the rooms were found to be negative pressure rather than positive pressure. Negative pressure means that the room is pulling air from adjacent areas which can potentially mean they are pulling dirty air into the rooms. While positive pressure in these rooms is pulling air through special filters and pushing it into rooms. Which will help prevent unfiltered air getting into the sterile room. This is checked by the engineering staff and was fixed in just a few minutes but in the end it was a big finding. “Ventilation • Maintain positive-pressure ventilation in the OR and maintain a minimum of 15 air changes per hour (of which at least 3 should be fresh air). • Keep the OR doors closed except as needed for passage of equipment, staff, and the patient. • Suggested: Limit the number of staff entering the OR to only those necessary.” (Adams, 2000) This information given from this article is still accurate today and this was explained to most of our staff. They have also already come up with a plan to frequently check the pressure of these rooms to insure they stay at positive pressure.

Another finding was that single use tools were being found in sterile tool kits. There are tools that we get at the hospital that are a part of our supply rooms. These tools found in our supply rooms are sterile but are not meant to be sterilized again. “a single-use device, also referred to as a disposable device, [is] intended for use on one patient during a single procedure. It is not intended to be reprocessed (cleaned, disinfected/sterilized) and used on another patient.” (FDA, 2001) There are many points of contact, and someone could have accidently put a single use tool in the kit by mistake. It is unfortunate, but our hospital educated us on this issue and now we all have a good understanding of what is considered a single use tool.

Little Company of Mary Hospital is a great hospital and has handled these findings well to insure they won’t be a problem again. By finding these issues our hospital will only improve and continue to educate others to keep our hospital for patients.

Explain the role of accreditation in mitigating risk compliance issues.  Provide an example of a health care organization that was placed on probation by its accrediting body or by CMS within the last 3 years for a risk compliance issue. What caused the probation or loss of accreditation and how could it have been prevented?


Using 200-300 words APA format with at least two references. Sources must be published within the last 5 years