Nurse Manager

Category - Performance

Your medical center has recently had two episodes of wrong site surgery. As you serve on the performance improvement work group that is chartered to address this issue, it is important to ask which question over and over again to get down to the root cause of this medical error?
  1. Who did it?
  2. What departments contributed to it?
  3. What should the staff have done?
  4. Why did it happen?
Explanation
Answer: D - The question that should be asked over and over again to get down to the root cause of this medical error is, “Why did it happen?”. Questions like “Who did it?”, What departments contributed to it?” and “What should the staff have done?” seek to place blame on people and groups of people. Performance will improve when patient safety issues are explored in a blameless culture.

Category: Performance improvement - Patient safety
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