Patient Safety and Quality Improvement
Core concepts
Safety science includes human factors, system thinking, and a nonpunitive culture of reporting. Know the difference between an adverse event (harm occurred), a near miss (no harm, caught in time), and a sentinel event (unexpected death or serious injury). Root cause analysis examines systems after a sentinel event; failure mode and effects analysis is proactive. Quality frameworks include the Plan-Do-Study-Act cycle, structure-process-outcome measurement, and national patient safety goals such as correct identification, handoff communication, medication reconciliation, and fall and pressure injury prevention.
Traps in questions
Questions reward system-level fixes over blaming an individual. If a choice says "counsel the nurse" or "retrain staff" as the only action, look for a stronger option that changes the process or the environment. Another trap is confusing a rapid response with a code team, or confusing quarantine with isolation. Watch for questions that ask for the first action: usually assess, ensure safety, or stop the line before documenting.
Worked example
Two patients with the same last name are on one unit and a wrong-blood-draw near miss occurs. Rule of thumb: the best answer redesigns the process (barcode scanning, two-identifier verification at the bedside, separate labeling zones) rather than asking staff to be more careful.
Study strategy
For each safety goal, name the failure it prevents and the observable check that proves compliance.