Fundamentals · chapter 15 · Evidence-Based Research, Quality Improvement, and Collaborative Practice
Quality Improvement in Nursing
The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 6 practice questions with the reasoning.
Key points
Medical error mortality
In 2016, an earth-shaking article noted that if medical errors were classified as diseases are, they would be the third-largest cause of death in the United States (Makary Daniel, 2016).
Safety event frequency
It is estimated that there are over 110 safety events for every 1,000 hospitalizations.
Cost of safety events
Over 11 percent of hospitalized patients will experience such an event, adding thousands of dollars to patient stays and costing too many lives (Finkelman, 2022).
Core QI focus
For healthcare providers, the core focus of quality improvement is to decrease errors (Sherwood Barnsteiner, 2022).
QI as core competency
The American Nurses Association (ANA) considers quality improvement, like evidence-based practice (EBP), to be one of the five core competencies of all healthcare professionals (ANA, 2021).
Nurses and continuous improvement
In fact, all nurses and healthcare providers must actively engage in ongoing and continuous improvement projects to improve health care for our patients and communities.
QI nurse role
Quality improvement nurses work with individual nurses, unit leadership, and facility leadership to ensure consistent quality related to current policies and procedures; they engage in the QI process across the agency, department, or facility.
QA nurse data review
Quality assurance nurses review the data on errors and poor patient outcomes at the facility.
PDSA cycle steps
The cycle involves four steps: developing a plan (Plan), running a test (Do), analyzing the results and comparing them to the desired results (Study), and making a plan for the next step (Act).
Medication error investigation
For example, after a medication administration error, a QI nurse might be called in to investigate the issue.
QI outcome measurement
Further, QI activities should offer measurable outcomes to clearly show their value (or their failure to achieve the expected value) (O’Donnell Gupta, 2023).
Nursing knowledge and resources
Using nursing knowledge to develop QI initiatives can allow for realistic identification of necessary resources versus superfluous ones.
Frontline nurses and innovation
Nurses are perfectly positioned as healthcare innovators thanks to their direct role in patient care and advocacy.
Streamlining nursing work
Quality improvement strategies can be used by and for nurses to streamline their work, resulting in increased time at the bedside and higher-quality care (Kelly, 2022).
Terms to know
- error
- An error is a failure to carry out a planned healthcare action or to complete the action correctly, with the result that the patient is harmed or experiences a less favorable outcome.
- adverse event
- An adverse event is one in which a patient is harmed or killed due to care that is being delivered, not to their underlying health condition.
- preventable adverse event
- A preventable adverse event is related to human error, such as errors of diagnosis, medication administration, treatment delays, and lack of follow-up (Sherwood Barnsteiner, 2022).
- sentinel event
- A sentinel event is an adverse event that happens in a healthcare setting, based on an accident (such as fall) or the actions of healthcare workers and results in patient death or permanent disability.
- Quality improvement (QI)
- Quality improvement (QI) is a framework used to improve patient care and outcomes systematically and continuously.
- quality assurance (QA)
- One component of a quality program is quality assurance (QA), the provision of oversight to ensure that, across a department or agency, the staff is receiving education and support to maintain the current quality standards.
- Quality Assurance and Performance Improvement (QAPI)
- Quality Assurance and Performance Improvement (QAPI) is the dual use of QA and performance improvement (PI), specifically in post acute care environments such as rehabilitation centers and nursing homes.
- root cause analysis
- This investigation may include a root cause analysis, which is a structured process to determine factors that underlie errors and adverse events (AHRQ, 2019).
Practice questions
Stuck on select-all-that-apply? How to take them one option at a time.
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Every question here, with the answer
A hospitalized patient falls while being transferred and sustains a permanent disability. The charge nurse is preparing the event report. Which classification best fits this event?
- Adverse event caused by the progression of illness
- Quality assurance activity
- Evidence-based practice change
- Sentinel event
Answer: Sentinel event
This event occurred in a healthcare setting, was based on an accident, and resulted in permanent disability, which meets the section’s definition of a sentinel event. Deaths or poor outcomes related to progression of illness are not sentinel events, and QA or EBP describe processes rather than this event classification.
A nurse manager is planning staff expectations for quality of practice on a medical-surgical unit. Which activities should the manager include as nursing responsibilities for quality improvement? Select all that apply.
- Recommend strategies to leadership to improve nursing practice.
- Use evidence-based practice to improve patient outcomes.
- Limit QI participation to nurses who have QI certification.
- Collect data to monitor the quality of care.
- Collaborate with other disciplines to implement QI.
Answer: Recommend strategies to leadership to improve nursing practice., Use evidence-based practice to improve patient outcomes., Collect data to monitor the quality of care., Collaborate with other disciplines to implement QI.
The section states that quality of practice includes using EBP, collecting data, recommending strategies to leadership, participating in QI, and collaborating with other disciplines. These standards apply to all nurses, not only nurses with QI certification.
Several medication administration errors have occurred on one unit. A QI nurse completes a root cause analysis and determines that the problem is related to a confusing unit-wide process rather than one nurse’s practice. What is the most appropriate next action by the QI nurse?
- Retrain only the nurse who made the most recent error.
- Stop the investigation because the error was not intentional.
- Refer the event only to a specialty professional nursing association.
- Develop a QI intervention to address the process problem.
Answer: Develop a QI intervention to address the process problem.
When root cause analysis shows a systemic issue, the section states that the QI nurse may develop a QI intervention. Retraining one nurse is more appropriate when the issue is unique to that nurse, not when the process itself is the root cause.
A unit is using the Plan-Do-Study-Act cycle to improve delays in patient follow-up. After developing a plan and running a test of the change, which actions are consistent with the PDSA cycle? Select all that apply.
- Declare the strategy successful without reviewing outcome data.
- Modify the plan based on what was learned before running the cycle again.
- Analyze the results of the test.
- Make a plan for the next step.
- Compare the results with the desired results.
Answer: Modify the plan based on what was learned before running the cycle again., Analyze the results of the test., Make a plan for the next step., Compare the results with the desired results.
In the PDSA cycle, after planning and doing, the team studies the results by analyzing and comparing them to desired results, then acts by planning the next step. The cycle may be repeated with modifications based on what was learned; declaring success without reviewing data is not consistent with the process.
Nurses on a unit report that they spend excessive time gathering supplies because equipment is stored inefficiently, and they also perform duplicate tasks during routine care. Which QI strategy is most directly aimed at this problem?
- Magnet recognition
- Lean
- Root cause analysis
- Quality Assurance and Performance Improvement certification
Answer: Lean
Lean is designed to remove unnecessary steps and reduce waste, such as duplicate tasks or inefficient unit layout that increases time and motion. The other options may relate to quality, but they are not the QI method described in the section for reducing waste in daily workflow.
A newly hired nurse asks which organizations or programs can support quality and safety work in nursing practice. Which responses by the preceptor are accurate? Select all that apply.
- Magnet recognition is awarded to individual nurses after they pass a subject-matter examination in QI.
- The ANA establishes the Scope and Standards of Practice and Code of Ethics for RNs and advanced practice nurses.
- The Joint Commission provides annually updated national patient safety goals for many hospital settings.
- AHRQ provides toolkits and best practice evidence for healthcare professionals.
- NCCMERP focuses on safe medication use and awareness of medication errors.
Answer: The ANA establishes the Scope and Standards of Practice and Code of Ethics for RNs and advanced practice nurses., The Joint Commission provides annually updated national patient safety goals for many hospital settings., AHRQ provides toolkits and best practice evidence for healthcare professionals., NCCMERP focuses on safe medication use and awareness of medication errors.
The ANA, AHRQ, The Joint Commission, and NCCMERP are all described as resources or organizations related to nursing quality and safety. Magnet recognition applies to healthcare organizations that provide high-quality nursing care, not to individual nurses after a QI examination.
Where every quote comes from
Section 15.3 Quality Improvement in Nursing of Fundamentals of Nursing by Christy Bowen, Lindsay Draper, Heather Moore, OpenStax, 2024. Read the whole section free at openstax.org.
The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.