discuss proposed changes in the Quality Assurance program secondary to a “never event” occurring in your organization

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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 such as wrong site surgery, wrong medication given, wrong blood transfusion given, etc.
  4. Discuss how you would go about examining the validity of their statements.
  5. What measures you would implement on an ongoing basis to prevent a recurrence of the “never event”.

In this module, you also learned about 4 approaches to quality assurance- TQM, CQI, Lean & Six Sigma.

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  1. Which of these approaches would lend to preventing a “never event”? Justify your answer.

Cantrell, S. (2016). Tooling up to prevent never events. Northfield: Healthcare Purchasing News.

Dimsdale, J. E. (2017). Assuring quality health care outcomes: lessons learned from car dealers? Patient Related Outcome Measures, 8, 1–6.

Gleeson H, Calderon A, Swami V, et al. (2016). Systematic review of approaches to using patient experience data for quality improvement in healthcare settings. BMJ Open 2016;6:e011907.

Ha, C., McCoy, D. A., Taylor, C. B., Kirk, K. D., Fry, R. S., & Modi, J. R. (2016). Using Lean Six Sigma methodology to improve a mass immunizations process at the United States Naval Academy. Military Medicine, 181(6), 582-588.

Health and medicine – health organization and management; University of Malta details findings in health organization and management (continuous quality improvement in a Maltese hospital using logical framework analysis). (2017). Health & Medicine Week, , 5215.

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