NURS-FPX4020
Improving Quality of
Care and Patient Safety
Q & A w/ Rationales
2024
,1. A nurse is conducting a root cause analysis (RCA) of a
medication error that occurred in her unit. She interviews
the staff involved, reviews the incident report, and
examines the medication administration process. What is
the next step in the RCA?
a) Identify the contributing factors and root causes of the
error
b) Develop an action plan to prevent similar errors in the
future
c) Implement the action plan and monitor its effectiveness
d) Communicate the findings and recommendations to the
stakeholders
*Answer: a) Identify the contributing factors and root
causes of the error
Rationale: The RCA is a systematic method of identifying
the underlying causes of an adverse event and developing
strategies to prevent recurrence. The steps of the RCA are:
1) Define the problem and gather data, 2) Identify the
contributing factors and root causes, 3) Develop an action
plan, 4) Implement the action plan and monitor its
effectiveness, and 5) Communicate the findings and
recommendations.*
2. A nurse is leading a quality improvement (QI) project to
reduce catheter-associated urinary tract infections
(CAUTIs) in her unit. She uses the Plan-Do-Study-Act
(PDSA) cycle as a framework for implementing changes.
She has already planned a change (using a checklist for
catheter insertion and maintenance), done the change
, (trialled the checklist for one month), and studied the
change (collected data on CAUTI rates and staff feedback).
What is the next step in the PDSA cycle?
a) Plan another change based on the results of the first one
b) Do another trial of the same change with a larger sample
size
c) Study the impact of the change on other outcomes, such
as patient satisfaction and length of stay
d) Act on what was learned from the change and decide
whether to adopt, adapt, or abandon it
*Answer: d) Act on what was learned from the change and
decide whether to adopt, adapt, or abandon it
Rationale: The PDSA cycle is a method of testing and
implementing changes for QI. The steps of the PDSA cycle
are: 1) Plan a change, 2) Do a small-scale test of the
change, 3) Study the results of the test, and 4) Act on what
was learned. The act step involves making a decision about
whether to continue, modify, or discontinue the change
based on the data and feedback.*
3. A nurse is participating in a rapid response team (RRT)
that responds to patients who show signs of clinical
deterioration. She recognizes that effective communication
among team members is essential for patient safety. She
uses a structured communication tool called SBAR
(Situation-Background-Assessment-Recommendation) to
report her observations and concerns to the team leader.
What are some benefits of using SBAR?
a) It ensures that all relevant information is shared in a
clear and concise manner
Improving Quality of
Care and Patient Safety
Q & A w/ Rationales
2024
,1. A nurse is conducting a root cause analysis (RCA) of a
medication error that occurred in her unit. She interviews
the staff involved, reviews the incident report, and
examines the medication administration process. What is
the next step in the RCA?
a) Identify the contributing factors and root causes of the
error
b) Develop an action plan to prevent similar errors in the
future
c) Implement the action plan and monitor its effectiveness
d) Communicate the findings and recommendations to the
stakeholders
*Answer: a) Identify the contributing factors and root
causes of the error
Rationale: The RCA is a systematic method of identifying
the underlying causes of an adverse event and developing
strategies to prevent recurrence. The steps of the RCA are:
1) Define the problem and gather data, 2) Identify the
contributing factors and root causes, 3) Develop an action
plan, 4) Implement the action plan and monitor its
effectiveness, and 5) Communicate the findings and
recommendations.*
2. A nurse is leading a quality improvement (QI) project to
reduce catheter-associated urinary tract infections
(CAUTIs) in her unit. She uses the Plan-Do-Study-Act
(PDSA) cycle as a framework for implementing changes.
She has already planned a change (using a checklist for
catheter insertion and maintenance), done the change
, (trialled the checklist for one month), and studied the
change (collected data on CAUTI rates and staff feedback).
What is the next step in the PDSA cycle?
a) Plan another change based on the results of the first one
b) Do another trial of the same change with a larger sample
size
c) Study the impact of the change on other outcomes, such
as patient satisfaction and length of stay
d) Act on what was learned from the change and decide
whether to adopt, adapt, or abandon it
*Answer: d) Act on what was learned from the change and
decide whether to adopt, adapt, or abandon it
Rationale: The PDSA cycle is a method of testing and
implementing changes for QI. The steps of the PDSA cycle
are: 1) Plan a change, 2) Do a small-scale test of the
change, 3) Study the results of the test, and 4) Act on what
was learned. The act step involves making a decision about
whether to continue, modify, or discontinue the change
based on the data and feedback.*
3. A nurse is participating in a rapid response team (RRT)
that responds to patients who show signs of clinical
deterioration. She recognizes that effective communication
among team members is essential for patient safety. She
uses a structured communication tool called SBAR
(Situation-Background-Assessment-Recommendation) to
report her observations and concerns to the team leader.
What are some benefits of using SBAR?
a) It ensures that all relevant information is shared in a
clear and concise manner
