Title: Corrective Action Plan for Medication Handling and Storage Issues at Memorial Hospital

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Memorial Hospital is an inner city 400 bed academic medical center serving a low income diverse community. The majority of patients are insured by either Medicare or Medicaid. A recent Joint Commission (JC) inspection of the hospital found major deficiencies in the handling and storing of medications. A report of their findings was submitted to the Chief Executive Officer (CEO) of the hospital citing that on two 20 bed medical-surgical units medications that had expired were mixed in with current medications. The medications with expired use dates were not separated from the good medications.
Upon further inspection the JC team found that the required sign in sheets attesting to the review of all medication dates were signed by the Nurse Managers of these Units. Policy and Procedures (P&P) on the handling and storage of medications were up to date and readily available to all staff. The JC team approved of the P&P but did not find minutes or a sign in sheet showing the training of RN’s, LPN’s, Aides , Residents and Hospitalists who rotated through the Units. The Nurse Managers have been with the hospital an average of ten years and in fact participated in the last JC inspection eight years ago.
The JC gave the hospital one month to submit a corrective action plan or face severe penalties which could include stopping reimbursement from Medicare.
The CEO hired a consultant Ms. Jones to help develop the corrective action plan. Ms. Jones is a Registered Nurse with years of experience working with hospitals to prepare for JC inspections as well as develop as develop corrective action plans.
ASSIGNMENT: You are the consultant. In a four page double spaced paper 1: Identify the key issues and problems in this case—be specific; 2. What information, data additional resources do you need to help develop the plan; 3. Referring to the textbook and in detail describe the Performance Improvement strategy you would use and why; and 4. Is there leadership and motivation problem. In developing your corrective action plan refer to the textbook chapters on Leadership , Motivation, Performance Improvement, Teams and any other that will help you develop a plan that the hospital can adopt in one month.

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I can provide you with an outline for your four-page paper based on the information provided. You can expand on these points to create your paper:

Title: Corrective Action Plan for Medication Handling and Storage Issues at Memorial Hospital

1. Introduction (Approximately half a page)

  • Briefly introduce the case and the main issue: Medication handling and storage deficiencies identified by the Joint Commission (JC) inspection at Memorial Hospital.
  • Provide a brief overview of the hospital’s profile, patient population, and the severity of the problem.

2. Identification of Key Issues and Problems (Approximately one page)

  • Discuss the major issues identified in the case:
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