Your Complete Policy Management Partner
Everything your healthcare organization needs to confidently maintain accreditation compliance.
Robust document control and workflow management software solution
Simplify & automate policy access, review and approval across your organization
Web-based library of more than 18,000 customizable policy documents
Instantly access up-to-date policies, procedures & forms authored by MCN experts
Automated regulatory notification system of daily email or mobile alerts
Keep current with regulatory changes from more than a dozen federal regulatory bodies, including TJC & NIAHO
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MCN Healthcare has been indispensable to our accreditation compliance efforts. With Policy Manager, Policy Library and StayAlert!, we have peace of mind that our policies will always be up-to-date and easy to locate.
Beverly McKenzie, Compliance Programs Director, IASIS Healthcare
Helpful MCN Healthcare Resources
The Joint Commission (TJC) has released an implementation guide for National Patient Safety Goal 07.05.01 on surgical site infections (SSI). The guide is based on the results of TJC's SSI Change Project.
NPSG 07.05.01 requires accredited organizations to implement evidence-based practices for preventing surgical site infections. According to the Institute for Healthcare Improvement SSI's are a significant health concern and represent a large portion of healthcare-associated infections. Many SSI's are preventable. TJC's Implementation Guide for NPSG.07.0.01 includes 23 specific, effective practices to help prevent and reduce SSIs.
The information in the Guide is being provided free of charge by TJC to hospitals and is available by following the link below.
Included with today's notice are a selection of example policies and procedures that address SSI prevention strategies.
The Joint Commission (TJC) has published an article about common myths surrounding the sentinel event reporting process. A sentinel event is "...an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof." These types of events are called "sentinel" because they signal a need for immediate response and investigation.
Every Joint Commission manual has a section with standards that outline requirements for the management of sentinel events. For hospitals the requirements are, generally:
- Identify all sentinel events
- Appropriately respond to the event including timely investigation and root cause analysis
- Monitoring any changes put in place in response to the sentinel to ensure they are effective
Key points from TJC's new article include:
- The sentinel event reporting process is voluntary and non-punitive
- Unanticipated deaths are considered reviewable events
- Joint Commission and state reporting requirements are separate
- The need for a "for cause" survey following a sentinel event is determined by the severity if the incident and the systemic risk to patients
- Hospitals should have a sentinel event policy in place
Included with today's notice is an example sentinel event policy and procedure.
Sandoz US is conducting a voluntary nationwide recall to the hospital/user level of two lots of its Methotrexate Sodium, USP, 25 mg/mL, 40 mL vial injectable product in the US, due to the discovery of particulate matter in vials during routine quality examination of retention samples at the manufacturer. Parenteral injection of drug from the affected lots can lead to microembolisation in areas where the particles lodge. Clinical symptoms are not to be expected from these microemboli and Sandoz is not aware of any reports of related adverse events.
Methotrexate is an antimetabolite used in the treatment of neoplastic diseases, severe psoriasis, and rheumatoid arthritis, including polyarticular juvenile rheumatoid arthritis. The lot numbers and expiration dates of the two recalled lots are: CL0996 (expiration date 12/2013) and CJ4948 (expiration date 05/2013). These lots were distributed nationally across the US and to a single foreign country (Poland).
In the event that a patient experiences an adverse reaction or quality problem involving this product, they should immediately contact their healthcare professional as well as Sandoz to report the finding. The Sandoz Drug Information Direct Line is open at 800-525-2492, 24 hours/day, seven days a week, or reports can be made via email at email@example.com.
Read the MedWatch alert, including a link to the Recall Notice, at the link below.
Featured Policy Library Manuals
The Hazardous Materials and Waste Management Manual contains all the policies you need to meet hazardous material and waste management compliance. This manual is cross referenced to Joint Commission standards, NIAHO standards as well as OSHA Hazard Communication Standard 2012!Read more »
The Medical Office Policy and Procedure Manual is cross referenced to Joint Commission standards for Ambulatory Care and Primary Care Medical Homes and NCQA standards for Patient Centered Medical Homes. This manual includes policies that meet OSHA requirements for safety and infection control, Human Resources policies and Medical Office Compliance Plan and much more!Read more »
MCN Healthcare’s Comprehensive Long Term Care Manual contains over 600 policies and procedures that are cross-referenced to Joint Commission standards and CMS regulations. The LTC Manual addresses the following areas: Emergency Management, HR, Infection Control, Information Management, Leadership, Medication Management, Performance Improvement, Patient Care, Medical Records, Resident Rights and Waived TestingRead more »