Orginizational Compliance and Regulation

Compliance Issues Worksheet

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Use this worksheet to complete Prompt 6 of the OM002 Assessment.

Scenario Compliance Issue Recommended Course of Action

A patient is discharged without proper instructions for prescribed medication.

Violation of NPSG.03.06.01 Investigate why proper discharge protocols were not utilized.
A recent patient at your hospital contracts Methicillin-resistant Staphylococcus aureus (MRSA). All proper infection-control guidelines were followed. No violation occurred. Contact Infection control staff immediately and report the incidence as required.
A phlebotomist does not wash her hands before a blood draw for a post-operative patient.    
A patient complains that her hospital identification bracelet is causing a rash. She removes and discards it. The nurse administers medication based on a verbal identification because she recognizes the patient from her previous two shifts.    
A patient with no known drug allergies is given a drug. The patient has a reaction to the drug, goes into anaphylactic shock, and dies.    
An obese hospital patient requests that an aide help him to the bathroom. The aide requests assistance, but no one is available. The aide escorts the patient alone, and the patient falls.    
A nurse in the intensive care unit (ICU) disables an alarm on a machine used to monitor a critically ill patient. When asked about his decision to disable the alarm, he claims the beeping was bothering family members visiting the patient. The patient is treated without incident.    
The cleaning staff frequently positions a linen cart so that it blocks access to a fire door in a hospital corridor.    
A hospital built in the 1970s does not meet the new fire safety codes.    
A blood test indicates an emergency room patient has a serious and highly contagious disease. The blood test results are reported to the attending physician 90 minutes after they are known.    
An experienced nurse does not label oral medications for his intensive care unit (ICU) patients because he can identify the medications based on the shape and color of the pills.    
A healthy young women checks into the hospital for a minor outpatient procedure. She recognizes the pre-op nurse from her volleyball league. When the nurse asks about what medications she is taking, she withholds that she is taking antidepressants and anti-anxiety medications.    
During a pre-procedure verification, an elderly patient with early-stage dementia insists that her left hip will be replaced. Records indicate that her right hip is to be replaced. The operating room (OR) is behind schedule but the surgical team delays the operation to consult with the patient’s family.    
A surgeon delegates the marking of the procedure site for an upcoming surgery to a surgical resident.    
The operating room (OR) is running almost 2 hours behind schedule. A surgeon has six routine operations. He skips the time-out before the surgical procedures.    


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