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    Introduction to Quality Assurance

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    This is new subject would like some help on these questions. Thanks in advance.

    You are attending a general meeting with management to discuss proposed changes in the Quality Assurance program secondary to a "never event" occurring in your organization [you can consider any never event offered by the AHRQ]. After the presentation and during a question and answer period, several nurses indicate that the "never event" occurred because of inadequate staffing. Several surgeons joined the nursing staff in these allegations.

    - What would your response be to their statements?
    - Discuss what never event occurred that was discussed at this meeting. You must pick one never event.
    - Describe how you would address the staff immediately in that meeting.
    - Discuss how you would go about examining the validity of their statements.
    - Describe what methodology would be used to explore the validity of their statements.
    - What measures you would implement on an ongoing basis to prevent a recurrence of the "never event".

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    Solution Preview

    First of all, let's make sure we are on the same page. The term "never event" was first coined by Ken Kizer to refer to particularly shocking medical errors - things that should 'never' happen. These events are usually unambiguous errors (there is no question that it is a mistake), serious, and preventable. The National Quality Forum defined 27 never events in 2002. As of the 2011 revision, there are 29 events grouped in six categories (surgical, product or device, patient protection, care management, environmental, radiologic, and criminal).

    Some examples of never events include:
    - sexual assault of a patient
    - infant discharged to the incorrect mother
    - surgery on the wrong body part
    - surgery on the wrong patient
    - wrong blood type given during a transfusion, resulting in a hemolytic reaction

    In response to a never event, the standard procedure is:
    - apologize to the patient
    - report the event
    - perform a root cause analysis
    - waive costs directly related to the event

    For the purpose of your questions, the 'never event' that I am going to address is stage 3 or 4 pressure ulcers acquired after admission into a medical facility.

    1) Considering that ...

    Solution Summary

    Introduction to quality assurances are examined.