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A review of the case determined that her assigned nurse on night shift was an RN age 24 with nine months of experience in this unit. This was her third 12 hours shift in a row, and she was 29 weeks pregnant. There were 28 beds occupied with only two RNs and one patient technician, due to one vacancy and a call-in for illness. A review of the chart showed that the patient had been advised by the out-going nurse, who admitted her to the unit post-operatively, that she needed to ask for assistance with toileting for at least the next 24 hours due to the extensive back surgery and post-anesthesia response and pain medication.

The RN coming on shift had received bedside shift report at 7 pm and noted the patient sleeping, so the issue of patient assistance was not repeated. She checked on her again at 8 pm and administered the requested prn medication morphine for pain. She was busy with other patients and did not see the patient again until the patient fell at pm. The patient reported that she did not recall having been instructed to ask for assistance, as she was very groggy from the anesthesia. The risk manager found that the RN had not followed nursing policy for patient assessment 20 minutes after receiving pain medication, and had not done the recommended hourly rounding on the patient to assess for the.

The note in the chart indicated only that the patient requested pain medication, but did not provide specific nursing assessment details or comment that the patient had received the same dosage of morphine two hours earlier. Part Two — Factors and Actions Discusses the factors that contributed to event and how these factors could be addressed to minimize legal risks. Situational factors Nursing factors Human factors Organizational factors Explains whether the nurse was negligent or did her actions reach the level of malpractice and support your reasoning with research.

Describes your reasoning for what action would you recommend warning, probation, revocation of license if you were on the disciplinary committee of your Board of Nursing. National Center for Biotechnology Information , U. Show details Hughes RG, editor. Search term. Author Information Authors Ronda G. Affiliations Ronda G.

Hughes, Ph. E-mail: vog. Background The necessity for quality and safety improvement initiatives permeates health care. Quality Improvement Strategies More than 40 years ago, Donabedian 27 proposed measuring the quality of health care by observing its structure, processes, and outcomes.

Six Sigma Six Sigma, originally designed as a business strategy, involves improving, designing, and monitoring process to minimize or eliminate waste while optimizing satisfaction and increasing financial stability.

Root Cause Analysis Root cause analysis RCA , used extensively in engineering 62 and similar to critical incident technique, 63 is a formalized investigation and problem-solving approach focused on identifying and understanding the underlying causes of an event as well as potential events that were intercepted. Failure Modes and Effects Analysis Errors will inevitably occur, and the times when errors occur cannot be predicted. Research Evidence Fifty studies and quality improvement projects were included in this analysis.

Some physicians would notaccept the new protocol and thwarted implementation until they had confidence in the tool. Hospital leadership was not adequately engaged. There was insufficient emphasis on importance and use of measures. The number and type of collaborative staffing was insufficient. The time required for nurses and other staff to implement the changes was underestimated. The extent to which differences in patient severity accounted for results could not be evaluated because severity of illness was not measured.

Improvements associated with each individual PDSA cycle could not be evaluated. The full impact on the costs of care, including fixed costs for overhead, could not be evaluated. Failure to consider the influence of factors such as fatigue, distraction, time pressures. The Hawthorne effect may have caused improvements more so than the initiative. Many factors were interrelated and correlated.

There was a lack of generalizability because of small sample size. Addressing some of the problems created others e. Targets set e. Evidence-Based Practice Implications From the improvement strategies and projects assessed in this review, several themes emerged from successful initiatives that nurses can use to guide quality improvement efforts. The strength of the following practice implications is associated with the methodological rigor and generalizability of these strategies and projects: The importance of having strong leadership commitment and support cannot be overstated.

Leadership needs to empower staff, be actively involved, and continuously drive quality improvement. Without the commitment and support of senior-level leadership, even the best intended projects are at great risk of not being successful. Champions of the quality initiative and quality improvement need to be throughout the organization, but especially in leadership positions and on the team. A culture of safety and improvement that rewards improvement and is driven to improve quality is important.

The culture is needed to support a quality infrastructure that has the resources and human capital required for successfully improving quality. Due to the complexity of health care, multidisciplinary teams and strategies are essential. Quality improvement teams and stakeholders need to understand the problem and root causes.

There must be a consensus on the definition of the problem. To this end, a clearly defined and universally agreed upon metric is essential.

This agreement is as crucial to the success of any improvement effort as the validity of the data itself. Use a proven, methodologically sound approach without being distracted by the jargon used in quality improvement.

The importance given to using clear models, terms, and process is critical, especially because many of the quality tools are interrelated; using only one tool will not produce successful results.

Standardizing care processes and ensuring that everyone uses those standards should improve processes by making them more efficient and effective—and improve organizational and patient outcomes.

Efforts to change practice and improve the quality of care can have multiple purposes , including redesigning care processes to maximize efficiency and effectiveness, improving customer satisfaction, improving patient outcomes, and improving organizational climate. Appropriate use of technology can improve team functioning, foster collaboration, reduce human error, and improve patient safety. Continually collect and analyze data and communicate results on critical indicators across the organization.

The ultimate goal of assessing and monitoring quality is to use findings to assess performance and define other areas needing improvement. Research Implications Given the complexity of health care, assessing quality improvement is a dynamic and challenging area. Some key areas are offered for consideration: How can quality improvement efforts recognize the needs of patients, insurers, regulators, patients, and staff and be successful?

What is the best method to identify priorities for improvement and meet the competing needs of stakeholders? What is the threshold of variation that needs to be attained to produce regular desired results? How can a bottom-up approach to changing clinical practice be successful if senior leadership is not supportive or the organizational culture does not support change? Conclusions Whatever the acronym of the method e. Evidence Table Quality Methods. References 1. National Healthcare Quality Report.

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. A strategy for quality assurance in Medicare. N Engl J Med. To err is human: building a safer health system. Failure mode and effects analysis in improving a drug distribution system. Am J Health Syst Pharm. Basics of quality improvement in health care.

Mayo Clin Proc. Public reporting on quality in the United States and the United Kingdom. Health Aff. Loeb J. The current state of performance measurement in healthcare. Int J Qual Health Care. National Healthcare Disparities Report. Health Affiars. J Healthc Qual. The public release of performance data: what do we expect to gain, a review of the evidence.

Schneider EC, Lieberman T. Publicly disclosed information about the quality of health care: response of the U. Qual Health Care. Health Affairs. How Pennsylvania hospitals have responded to publicly release reports on coronary artery bypass graft surgery.

Jt Comm J Qual Improv. The nonspread of innovations: the mediating role of professionals. Acad Manage J. Glouberman S, Mintzberg H. Managing the care of health and the cure of disease— part I: differentiation.

Health Care Manage Rev. Mediating the cultural boundaries between medicine, nursing and management—the central challenge in hospital reform. Health Serv Manage Res. Gaba DM.

Structural and organizational issues is patient safety: a comparison of health care to other high-hazard industries. Calif Manage Rev. Does what nurses do affect clinical outcomes for hospitalized patients?

A review of the literature. Health Serv Res. Taylor C. Problem solving in clinical nursing practice. J Adv Nurs. Benner P. From novice to expert: power and excellence in nursing practice. Learning from samples of one or fewer. Organizational Science. Developing a clinical performance measure. Am J Prev Med. McGlynn EA. Choosing and evaluating clinical performance measures. Gift RG, Mosel D. Benchmarking in health care.

Donabedian A. Evaluating quality of medical care. Milbank Q. Deming WE. Out of the Crisis. Curing health care. Sustainability in changing clinical practice promotes evidence-based nursing care. Berwick DM. Developing and testing changes in delivery of care. Ann Intern Med. Chassin MR. Quality of Care—part 3: Improving the quality of care. Can evidence-based medicine and outcomes research contribute to error reduction? Medical error: what do we know?

What do we do? Joss R. Nwabueze U, Kanji GK. The implementation of total quality management in the NHS: how to avoid failure. Total Quality Management. Jackson S. Successfully implementing total quality management tools within healthcare: what are the key actions?

Rago WV. Struggles in transformation: a study in TQM, leadership and organizational culture in a government agency. Public Adm Rev. Furman C, Caplan R. Appling the Toyota production system: using a patient safety alert system to reduce error. Lean thinking. New York: Simon and Schuster; The ethics of using quality improvement methods in health care. Differentiating quality improvement from research. Appl Nurs Res. Blumenthal D, Kilo CM. A report card on continuous quality improvement.

Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Lynn J. When does quality improvement count as research? Human subject protection and theories of knowledge. Qual Saf Health Care.

Bellin E, Dubler NN. The quality improvement-research divide and the need for external oversight. Am J Public Health. Choo V. Thin line between research and audit. Harrington L. Quality improvement, research, and the institutional review board. Eleven worthy aims for clinical leadership of health care reform. Improvement, trust, and the healthcare workforce. The improvement guide: a practical approach to enhancing organizational performance.

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