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In the Quality Improvement module, you learned about the most commonly used QI model, plan-do-study-act (PDSA). For this assignment, review the scenario and respond to the questions. A nurse manager has noticed an increase in the number of clients whose conditions decline before healthcare providers are made aware of critical lab or testing results, causing a delay of prescribed treatments. In one case, a client died before treatment was provided to address the critical lab results. A nurse performs a chart audit and learns that nursing staff are not routinely documenting when healthcare providers are being notified of critical lab or testing results. When discussing the issue with providers, they often indicate they were not made aware of critical lab or testing results in a timely manner. When discussing the issue with nursing staff, they indicate the results may not be flagged in the electronic health record (EHR), causing the critical lab results to be discovered later in the shift. The manager recognizes that the healthcare providers, nursing staff, clients, and departments who do testing and labs are among the stakeholders involved in the concerning trend; a QI team is developed from the stakeholders. The nurse manager holds a meeting with the QI team and makes a plan to immediately notify nursing staff and providers of critical results. All stakeholders are educated about the new process, and the process is implemented. The new process involves text alerts on nurse’s and provider’s phones that need to be acknowledged within 10 minutes. If the text alert is not acknowledged, the nurse and provider will be called with the critical results. After following the process for three months, the nurse manager reviews the information and finds that fewer clients are experiencing declines in their conditions before treatment measures can be implemented. A chart audit now shows that nursing staff are still lacking in documenting when providers are notified of critical lab or testing results. Respond to the following questions and provide an evidence-based rationale. 1. Indicate the activities in the scenario that are part of each step of the PDSA process. Provide a rationale for your responses. 2. If the QI team were to use a process flow chart, how would it assist to address the problem in the scenario? Provide a rationale for your response. 3. What type of (category) audit has the nurse manager demonstrated in the scenario? Provide a rationale for your response. 4. Indicate whether the scenario represents a sentinel event or medical error based on the definition provided in the lesson. 5. Provide a rationale for your response. Indicate whether this QI process, described in the scenario, could meet the objective of cost-effective care. Provide a rationale for your response.
6. What is a nurse’s role in creating a culture of safety?
7. How does preventing injury to employees of a healthcare facility contribute to the culture of safety?
8. Describe the differences between a near miss event, a client safety event, an adverse event, and a sentinel event. 9. Explain the potential impact fatigue could have on the culture of safety in health care environments.
*References Needed, APA style, in text citation. Full paper not needed. Only questions answered.*
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