House Staff Manual - Winthrop University Hospital

then cross check the bracelet with the voucher for test or procedure, prescribed medication, menu, chart,etc. If there is any discrepancy, it should be brought immediately to the attention of the patient's nurse.Identification bracelets should not be cut when performing tests or procedures. If the circumstances areacute, and cutting is unavoidable, the nurse should be advised so that a replacement bracelet can bereapplied immediately.75. PATIENT RESTRAINTSBased on JCAHO Standards, restraint usage is to be discouraged and may be used on a temporary basisafter alternatives have been attempted and found unsuccessful. Research has demonstrated that restraintusage can be detrimental to patient care, negatively affecting may body systems and patient outcomes.A Restraint is defined as the direct application of physical force to a patient, with or without the patient’spermission, to restrict his or her freedom of movement. The physical force may be human, mechanicaldevices or a combination thereof. (See Patient Care Manual Policy # P-30-5). Restraints are time limitedfor a maximum of 24 hours. Each new episode of restraint requires a face to face assessment by thepractitioner before reordering. Order is completed using the Restraint Doctor’s Order sheet.76. QUALITY MANAGEMENTThe Joint Commission on Accreditation of Health Care Organizations, as well as the New York StateDepartment of Health (405.6), mandates that all hospitals establish and maintain a Quality ManagementProgram. Clinical departments and Medical Staff committees are responsible to the Executive Committeeof the Medical Staff and the Board of Directors for assuring the implementation of a planned and systemicprocess for monitoring, evaluating and improving patient care. This process is accomplished via regularreview of at least the following:- Mortalities - Re-admissions- Morbidities - Infections- Complications - Drug Usage- Unplanned Surgery - Transfusions- Incidents - Patient RelationsReviews focus on specific indicators or referrals, defining the cause and scope of the event, resolving issuesat the lowest institutional level possible, and monitoring the effectiveness of corrective actions. Issues aretrended according to event, as well as practitioner, in order to determine patterns of care.Clinical department chairpersons are responsible for conducting and coordinating the Quality Managementactivities of their departments. Quality Management issues are addressed regularly at monthlydepartmental meetings, during which time representatives of the House Staff, traditionally chief residents,have an opportunity to observe and participate in the process. Subsequently, the chiefs educate their housestaff accordingly. Further House Staff participation on a peer review level is at the discretion of theDepartment Chair.The Quality Management staff is available for further questions at ext. 2510 and may be contacted if thereis a question concerning quality management policy in general.77. REFUSAL OF TREATMENTA competent adult has a right to refuse any and all treatment on his or her own behalf. In the event apatient refuses treatment, the patient must be clearly and completely informed of the potential risk tohis/her health and welfare. The physician must document in the patient's medical record the discussionwith the patient of the risks and alternatives of the contemplated treatment. This will protect the physicianagainst any claims by patients that they would not have refused treatment had they been aware of thepotential consequences.Rev. 1/08