Patient Safety and Quality Assurance
This domain tests error science, incident reporting, root-cause analysis, quality improvement, communication, and the Israeli Ministry of Health risk-management approach.
Core rules
- Adopt a just culture: distinguish human error, at-risk behaviour, and reckless conduct.
- Report incidents and near misses through the institutional system; reporting is for learning, not punishment.
- Use root-cause analysis for serious events to identify system failures rather than blaming an individual.
- Apply quality-improvement cycles such as PDSA and track indicators, including falls, pressure injuries, medication errors, and infections.
- Use structured handoffs such as SBAR and verify patient identity before procedures and medication administration.
- Disclose harmful errors to patients honestly and document the disclosure.
Worked example
A nurse notices that a patient received the wrong dose of insulin but the glucose is stable. Do not hide the event. Assess and treat the patient, notify the prescriber, report the incident, and disclose the error to the patient. Then examine system factors such as look-alike packaging, staffing, and the double-check process. Reason: reporting and system analysis prevent recurrence; concealment endangers the patient and undermines safety culture.
Traps
- Punishing the reporter and driving errors underground.
- Treating near misses as unimportant.
- Blaming one nurse instead of fixing the system.
- Using informal handoffs without a structured format.