Safety and Quality Improvement
What this domain tests
Safety and Quality Improvement tests human factors, error prevention, adverse event reporting, root cause analysis, and improvement methods.
Core rules
- A sentinel event is an unexpected occurrence causing death or serious harm; it triggers immediate investigation and disclosure.
- Root cause analysis is retrospective and system-focused; failure mode and effects analysis is prospective.
- The PDSA cycle (Plan-Do-Study-Act) tests small changes before spread.
- Just culture separates human error from at-risk behavior and reckless behavior; it encourages reporting rather than blame.
- Falls: assess risk on admission and after change, use bed alarms, non-slip footwear, hourly rounding, and keep call bells within reach. Restraints are a last resort.
- Incident reports are for learning, not punishment, and are not placed in the medical record.
Worked example
A unit notices falls rose from 2 to 8 per 1,000 patient days after a staffing change. What is the best next step? Reasoning: define the problem with data, review each fall for contributing factors, and use a PDSA cycle to test one change, such as hourly rounding or a bed-exit alarm protocol. Measure again and spread only if the change works. Blaming individual nurses does not address the system.
Traps
- Disciplining the reporter of an error instead of examining the process.
- Putting incident reports in the chart.
- Confusing quality assurance with quality improvement; QA checks compliance, QI tests change.
- Assuming a low fall rate means no risk; underreporting is common.