Four team leaders on a medical unit are meeting with the nurse manager to review CQI data for the last quarter. The data concerns medication errors, falls, and nosocomial infections. The QI Department provided data in the form of a graph. The nurse manager expresses concern about the changes in the data compared to the previous quarter. They discuss the impact these changes may have in light of the new CMS hospital-acquired complications (HACs) policy. One of the team leaders says that she thinks the problem is staff not taking this seriously and all of the team leaders need identify individual staff who make all the errors. Another team leader argues with her, saying that this is too narrow a view of the problems and focuses on blame. The other two team leaders did not say anything, but they also are confused about how staff respond to errors. Most of the team leaders feel it is their job to focus on individual errors. The nurse manager says that the staff needs to come up with a plan to address the changes in unit CQI data. She also says, “I think we really need to address our culture of safety.”

 

1. 
Review the data provided in the graph. What does the data tell you?

2.
Develop a plan to focus on the problems in the next quarter by identifying goal, interventions, and methods to evaluate outcomes. Use the Food and Drug Administration (FDA) Safe Use Initiative information that focuses on collaborating to reduce preventable harm from medications to develop the implementation plan to reduce drug errors and the four stages of the drug system identified by the FDA. (See FDA website.)

3.
How would you address the culture of safety on the unit?