Quality and Safety
Quality and Safety asks how you detect, measure, and prevent harm at the system level. Items test familiarity with improvement methods, reporting culture, handoff structure, and the metrics emergency departments actually track.
Improvement methods
- Plan-Do-Study-Act (PDSA) for rapid-cycle change; DMAIC for larger structured projects; run charts and statistical process control to separate real signal from normal variation.
- Root cause analysis after serious events; failure mode and effects analysis prospectively for high-risk processes.
- Just culture distinguishes human error (console), at-risk behavior (coach), and reckless behavior (sanction). Blame drives reporting underground.
Metrics worth knowing
- Door-to-provider interval, length of stay, left-without-being-seen rate, boarding time, ambulance offload.
- Bundle compliance: sepsis bundle elements, door-to-ECG for chest pain, door-to-needle for stroke.
- Harm measures: medication events, falls, hospital-acquired infection, restraint use, diagnostic error and unplanned returns.
Handoff and reliability
- Structured handoff (SBAR or I-PASS) with read-back; include pending results, contingency plans, and code status.
- Standardization, checklists, time-outs, and independent double-checks are high-reliability practices for high-consequence steps.
- Report near misses, not only harms; near misses are free lessons.
Worked example
Left-without-being-seen rate rose from 2.1% to 3.8% over three weeks, concentrated between 18:00 and 23:00. Reasoning: plot the data by hour before choosing an intervention. If the increase tracks evening boarding hours, a midshift staffing change is a testable change; a general reminder to staff would not be. Run it as a PDSA cycle with a predefined measure and review date.
Traps that cost marks
- Intervening before stratifying data by time, location, or population.
- Treating a single chart outlier as a trend.
- Assuming a low incident report count means a safe unit - it often means the opposite.
- Punitive response to a reported error, which stops the next report.
- Handoffs that omit pending results and contingency plans.