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Proposed Changes in the Quality Assurance Program

Module 1 – Case


Assignment Overview

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.

1. What would your response be to their statements?

2. Discuss what a “never event” is.

3. Discuss what never event occurred that was discussed at this meeting. You must pick one never event.

4. Describe how you would address the staff immediately in that meeting.

5. Discuss how you would go about examining the validity of their statements.

6. Describe what methodology would be used to explore the validity of their statements.

7. What measures you would implement on an ongoing basis to prevent a recurrence of the “never event”.

Please support your position with adequate references.

Assignment Expectations

Length: Case Assignment Module assignments should be at least 4-5 pages in length.

References: At least two references should be included from academic sources (e.g. peer-reviewed journal articles). Required readings are included.

Organization: Subheadings should be used to organize your paper according to question

Format: APA format is recommended (but not required) for this assignment. See Syllabus page for more information on APA format.

The following items will be assessed in particular:

Relevance (e.g. all content is connected to the question)

Precision (e.g. specific question is addressed. Statements, facts, and statistics are specific and accurate).

Depth of discussion (e.g. present and integrate points that lead to deeper issues)

Breadth (e.g. multiple perspectives and references, multiple issues/factors considered)

Evidence (e.g. points are well-supported with facts, statistics and references)

Logic (e.g. presented discussion makes sense, conclusions are logically supported by premises, statements, or factual information)

Clarity (e.g. writing is concise, understandable, and contains sufficient detail or examples)

Objectivity (e.g. avoid use of first person and subjective bias)

Proposed Changes in the Quality Assurance Program


            Never events have a significant impact on increased costs and patient harm. Frontline nurses have a huge role in helping prevent never events through creating a safety culture by using the best nursing practices. The frontline nurses have a critical role in preventing the occurrence of never events through evidence-based practice adoption and risk anticipation. In the latest study done by researchers from Washington University in St. Louis, 42% of the falls taking place in hospitals resulted to patient injury. In eight percent of the falls, patients in hospitals were critically injured with fractures or head trauma. According to the study, patients who mostly sustained critical fall-related injuries were either in the bathroom or on their way there.

Never event

            The words ‘never event’ were introduced by Ken Kizer in 2001 in reference to principally shocking medical errors that can be prevented from occurring and should never happen. For example, wrong-site injury. According to the CMS (Centers for Medicare and Medicaid Services), never events are preventable, serious, as well as costly medical errors. Overtime, the list of never events has been expanded. As such, unambiguous adverse events (clearly measurable and identifiable), serious (leading to significant disability and death), and preventable cases are signified.

The never event that occurred

            The never event that led to the staff meeting involved a fall and trauma. As far as hospitals’ preventable medical conditions are concerned, falls in trauma tops the list. It accounts for more than 194,000 incidents. Medicare deems falls in hospitals and nursing homes as preventable if there is proper risk or fall assessment as well as staff assistance. This would ensure that a majority of the falls in hospitals are avoided (Medcom, inc. & TRAINEX (Firm), 2009).  

Addressing the staff immediately in the meeting

            Current systematic reviews indicate that there is a consistent and strong relationship between certain adverse events and nurse staffing. This is more so with surgical patients and in the intensive care units. Urinary tract infections, hospital acquired infections, falls, pneumonia, blood stream infections, pressure ulcers, medication errors, and longer than anticipated hospital stays are strongly linked to poorer staffing. This is based on nurses having fewer nursing care hours per patient daily and a nurse having more patients than she can manage. Some of the intermediate variables mediating this relationship include quality and type of equipment, work environment, individual nurse experience, education and competency, organizational and clinical care processes, as well as the ability of communicating with team members (Medcom, inc. & TRAINEX (Firm), 2009).  

            In relation to the fall that occurred, there is a need to explore a number of factors so as to determine the risk of patients falling. This should include medications that have an impact on coordination and balance (Medcom, inc., 2009). Second, it should be established if there are any patients using assistive devices such as a cane or walker. In case there is, the facility should provide these patients at all times. The third factor is age where the elderly have a far much greater risk to falls compared to the younger counterparts. Finally, there is a need to assess if patients are in a position to use bathrooms on their own. If they are not able to, the staff should provide regular assistance.

Examining the statements’ validity

            The nursing staff and the surgeons support that the never event was as a result of inadequate staffing. The validity of this statement can be examined by making an analysis of the staff to patient ratio. This will help in determining if there are too many patients and less staff to care for these patients (Medcom, inc., 2009).

Methodology for exploring the validity

            My take is that questionnaires can be used to explore the validity of the statement. A questionnaire with questions related to the prevalence of falls in the institution, adequate staffing, efforts by the staff to prevent falls, and patient outcomes can be prepared and distributed among the staff, patients, and support staff. After analyzing the feedbacks they give, this can assist in exploring if the statement is valid or not.

Measures to be implemented to prevent a recurrence

            Having established the seriousness of falls as a never event, it is important for healthcare institutions to come up with strategies aimed at preventing a recurrence (Garber, Gross & Slonim, 2010).  There is a great need to determine patients that are at a greater risk of falling. In addition, there should be precautions to reduce the likelihood of falls as a result of inadequate staffing and sloppiness. Some of the measures that can be take include the following; removing clutter from floors, removing improperly fitting clothing and slippers, keeping the bed rails up whenever patients are sleeping, ensuring that there is sufficient equipment and staff when patients are being transferred out and into beds, installing handrails in all areas where patients require stability, call lights should be kept within the reach of residents in beds always, and the wheels on beds and wheelchairs should be locked when patients are being transferred.


Garber, J. S., Gross, M., & Slonim, A. D. (2010). Avoiding common nursing errors. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Medcom, inc. (2009). Never events and hospital-acquired infections. Cypress, CA: Medcom, Inc

Medcom, inc., & TRAINEX (Firm). (2009). Never events and hospital-acquired conditions. Cypress, CA: Medcom, Inc.

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