Submitted March 2005:

We had a 4-day surprise inspection for the hospital and our angio/cath lab the end of January. We certainly did not expect it so soon in the year. The following are some of the "biggies" that inspectors really went over with a fine-tooth comb:

1. The biggest was on the final "team pause" before ANY "procedure" being done, whether by doctor or P.A.

JCAHO wants to know when it was done, who did it, who was included, what was covered in the "pause," and how and where it was documented. Then inspectors randomly show up to see if that indeed is what is being done and if everyone is doing it the same way, especially if you are being surveyed as a Health Care System.

2. I.D. the patient using two identifiers before doing or giving the patient ANYTHING.

Inspectors watched very closely for this when following a patient.

3. In the cath lab, JCAHO made sure there was a signature by a doctor to back up everything we did, including meds given.

One way to solve this is to have the physician sign your print-out of the case.

Also, regarding signatures, JCAHO looked house-wide. With many facilities changing or having changed to a "paperless system," they want to make sure there is a way for the doctor to "sign" the reports and orders built into the system. MAKE SURE THIS IS BEING DONE once set up.