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Quality and Safety Scenario:
The Quality Assessment Nurse Council is meeting to review data from the last quarter. There has been a significant increase in medication errors and falls, with a decrease in nosocomial infections. Some of the team members want to focus on the nurses and unlicensed assistive personnel who are associated with the errors and counsel them and insist on additional training. Other members feel that the nursing staff do not take QI seriously and are concerned that the problems are going to continue. The team leader states that the problems are bigger than individual staff perceptions and errors and suggests that a plan be made to address the areas of need. She also states, “I think we need to look at the culture of safety on the unit.” (1) Discuss the QI report in terms of the CMS Never Events (2) Compare and contrast the Blame Culture with the Culture of Safety
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