During a root cause analysis, staff say that a wrong-patient procedure occurred because the nurse was careless. Which question best redirects the team toward system improvement?
Correct answer: A. What conditions made it possible for the wrong patient to be selected?
- A. What conditions made it possible for the wrong patient to be selected?
- B. Which individual should receive the most severe punishment?
- C. How can the incident be removed from the ward performance report?
- D. Which staff member should be asked to accept personal responsibility first?
Explanation
Root cause analysis asks how processes, communication, equipment, workload, or policies allowed the event to occur. Focusing only on blame may identify a person but does not prevent the same error under similar conditions.
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About Quality and Patient Safety
Quality and patient safety include standards of care, quality assurance, continuous quality improvement, audits, indicators and patient feedback. The subject also covers medication errors, falls, infections, communication failures, incident reporting, root cause analysis and preventive actions, distinguishing system improvement from assigning blame to an individual.
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