Quality Improvement & Safety Standards Flashcards

A nurse manager notices a recurring pattern of medication errors during shift changes. Which QI methodology is BEST suited to identify the root cause systematically?

Answer: Root Cause Analysis (RCA)

Root Cause Analysis (RCA) is specifically designed to identify underlying systemic causes of adverse events rather than assigning individual blame.

The Joint Commission's National Patient Safety Goal regarding patient identification requires staff to use at least how many patient identifiers before providing care?

Answer: Two

TJC NPSG 01.01.01 requires at least two patient identifiers to be used before administering medications, blood products, or performing procedures.

When a hospital's fall rate rises above the national benchmark, which step in the PDSA cycle should the team undertake FIRST?

Answer: Plan — define the problem and hypothesize a solution

The PDSA cycle begins with the Plan phase, where the team defines the problem, identifies aims, and develops a change theory before taking action.

Which of the following is a leading indicator of patient safety rather than a lagging indicator?

Answer: Percentage of staff compliant with hand hygiene audits

Hand hygiene compliance is a process (leading) measure that predicts future infection outcomes, while the other options reflect outcomes that have already occurred.

An ANM is reviewing a Failure Mode and Effects Analysis (FMEA) for the IV medication preparation process. What is the PRIMARY purpose of this tool?

Answer: To proactively identify potential failure points before they cause harm

FMEA is a prospective risk-assessment tool used to proactively identify where and how a process might fail before a patient is harmed.

A staff nurse reports a near-miss in which two patients with similar names were nearly given each other's medications. Under a Just Culture framework, the manager should FIRST:

Answer: Conduct a system analysis to identify contributing factors

Just Culture emphasizes evaluating system-level factors rather than defaulting to individual blame, especially for near-misses without harm.

Which accreditation body uses the Tracer Methodology to evaluate patient care quality in hospitals across the United States?

Answer: The Joint Commission (TJC)

The Joint Commission uses Tracer Methodology — following individual patient care episodes — as its primary survey evaluation strategy.